Tuesday, August 11, 2009

Mandating Health Benefits in Massachusetts

The Boston Globe recently reported that 70 bills requiring insurers to cover specific health services are pending in the Massachusetts legislature. Many of the proposed services are clearly desirable - such as hearing aids for children and treatments for cleft palate.

At the same time that 70 proposals to require new services are pending, the Massachusetts health care reform program is staggering under its burden of cost, and is considering cutbacks on coverage and services. What's going on?

The answer is - business as usual!

We currently make choice the top value for our health system - individual patient choice of physicians and hospitals, individual physician choice of treatments, and individual legislator choice of what to lobby for. Fear of losing choices is the biggest roadblock for national health care reform.

Virtually all of my clinical practice life has been in systems that (a) had overall budgets which (b) were allocated by a combination of expert leadership and patient involvement, with (c) processes that allowed appeal - by physicians or patients - when limits were encountered. But in the last 20 years we've had a big pendulum swing against this kind of managed approach.

I hope we in Massachusetts can come to our senses about the downsides of our choice mania. Runaway cost is the most obvious negative. But governing a health system by the sum of a billion individual choices is like trying to build a house without an plan for the foundation and how the parts will fit together. We haven't yet come to a public understanding of how much quality of care suffers from our lack of coordination.

Legislators who are lobbying for new benefits are focused on a particular choice, but without a sense of how that choice, which might be good in itself, impacts on the system it would play out in. What we're seeing in Massachusetts provides an argument for expert health boards that would be insulated from the kind of immediate public pressure that legislatures are subject to.

My work in ethics involves reflecting about what appears to be the best course of action and the right way to do things. What we're seeing now in the health reform process is the transition from ethics to politics. Our system of (a) relatively unfettered choice combined with (b) third party financing of those choices results in (c) superb market opportunities for the providers of services and, as the public is beginning to recognize (d) runaway costs which (e) undermine wages and national competitiveness. Enormous lobbying funds are fanning fear of "loss of choice to government bureaucrats."

If I were the czar of the health system I would decree dissemination of "accountable health organizations" modelled on Kaiser Permanente, Mayo Clinic, Geisinger, Harvard Vanguard, and other excellent managed clinical programs, in which patients and clinicians collaborate to make collective choices within budgets.

But organizations of this kind limit individual choice. The only alternative to collective self governance is individual risk for the cost of the choices we make. In Massachusetts our legislature is playing both sides of the coin at once - holding health care reform to a budget, but fracturing that budget by proposing 70 new choices. But unlike the federal government, the states can't run deficits, and can't as readily avoid the implcations of their choices. We need to learn to say "no" to ourselves. That's not likely to happen on the national level anytime soon. If we can't learn how to accept and manage limits at the state level we might as well toss in the health care towel.


Anonymous said...

Amen, brother! The right tells us we don't want "government bureaucrats meddling with our health care". The left says we don't want "insurance company bureaucrats meddling with our health care". I say SOMEBODY HAS TO MEDDLE.

Whether we pool our dollars in public pools or private pools, the incentives for both doctors and patients are to overuse the "commons". Someone must meddle to prevent that overuse.

We can argue about who meddles and how they meddle. We can meddle through global budgets or capitation or pay for performance. We can meddle through private companies or state government workers or federal government workers.


Jim Sabin said...

Hi Anonymous -

I'm sorry for the delay in responding to your comment - I've been out of the country for a couple of weeks.

I agree with you that one or another form of "meddling" is required. My preferred form is "deliberative meddling" - a form of democratic process in which many voices can be heard. In the 1990s, when we saw the tremendous backlash against "managed care," not enough people understood your point - the health system must be managed, and the only question is how we choose to carry out the management process.

Thanks for your comment!