One of the challenges for health reform legislation is the culture of the policy and political community.
Massachusetts’ insurance and coverage initiatives have been cited as lessons for health reform at the Federal level and other states. However, while observing a meeting of the state’s Special Commission on the Health Care Payment System last Friday, I was struck by how the culture of this group was very different than what I have often seen in Federal processes or within other states.
The Commission had agreed at their previous meeting that global payments should replace fee-for-service as the main payment route for medical services and products. At Friday’s meeting their discussion about what that system of global payments should eventually look like – and how to get there – was not confrontational, even though the Commission’s representation includes a wide range of stakeholders, including doctors, hospitals, two insurers, the state employees’ insurance plan and two elected representatives.
The collegiality and non-confrontational atmosphere of this Commission compared to national discussions of similarly broad groups – such as the Health Reform Dialogue – may provide important insights for other health reform efforts. The reasons why health reform in Massachusetts has this type of culture is probably a long list, but some of them might be:
- The stakeholders realize that payment reform is part of longer-term cost containment efforts that will be necessary for the overall success of the state’s insurance expansion program
- Despite the overall economic downturn, the state and its healthcare system are generally better off than other states and healthcare operations
- The state has a generally progressive bent, and is somewhat culturally aligned, e.g. almost everyone is a Member of Red Sox Nation
Whatever the reasons for the agreeablity within the Commission and the state, progress thus far has been a significant achievement, and could lead the way for significant reforms at the Federal level or within other states – particularly if they can replicate a similar culture of cooperation and agreement.
Next Challenging Steps
Of course, the Special Commission won’t be making all the detailed decisions necessary for actually reforming payments, such as:
- How quickly the new system will be initiated
- How much the global payments will be
- Who will get the global payments, e.g. hospitals, integrated delivery systems, physician groups, or some combination of providers
- What types of quality information those receiving the payments will have to provide
- What levels of cost containment will the new global payment system be expected to meet – and what measurements will be used to determine if costs are being constrained appropriately
Those types of decisions will be made by the state legislature and a government agency – or para-governmental entity created for these purposes. These upcoming decisions and their implementations will be where the even harder challenges await. However, given the Special Commission’s progress so far – and the state’s ability to implement and sustain the insurance expansion program – the likelihood that these harder steps will at least be partially successful seems good. So while critics have been predicting the downfall of the Massachusetts insurance coverage expansion experiment because of rising costs, that’s not the future I see.
The political and policy leadership in Massachusetts seem to have a sustainable group-think and desire to keep on the path they’ve started on rather than veering off into another direction to achieve immediate cost savings or politically expedient gains. The ability of the state to do this will be aided by some of the factors postulated above, as well as the political clout the state has in Congress, and the Governor’s relationship with the President. But those factors may change with time, so the ultimate ability of the state to sustain ongoing reforms and improvements to the healthcare system within the state may very well depend upon its momentum of success. They’ve had great success in reducing the number of people without health insurance. Now cost containment via payment system reform is the next success that must be achieved.