In the States
Talking about health care reform all over the country, I have the opportunity to see many states' health systems up close. In particular, we spend a lot of time in Colorado -- as evidenced by our study on Grand Junction. In the context of current reform discussions, I began focusing on the state in earnest in 2006 when the Colorado Blue Ribbon Commission for Health Care Reform began trying to identify a sustainable future for the state's health care system. It was a privilege to be consulted by the Commission -- a true bipartisan and multi-stakeholder effort -- about choices they could make to cover more Coloradans, improve the quality of care while reducing health care cost growth, and make the health system economically viable in the long run. At the end of a long and impressive (but surely exhausting) process, the Commission's recommendations look prescient, in that they are structurally and conceptually consistent with the federal health reform proposals under consideration today.
What is comparative effectiveness research? If you need a reminder: comparative effectiveness means comparing two or more treatments for the same health problem to see which one works best for patients. The question has popped up quite a bit since comparative effectiveness research showed up in the economic stimulus package alongside other common sense health reforms, such as health IT adoption. Comparative effectiveness is about giving doctors and patients more information and facts for decision-making, not about taking away their autonomy.
When it comes to health reform at a state level, the state that gets the most attention is usually Massachusetts. But other states, such as Vermont, Hawaii, and recently, Wisconsin, are starting to get recognition for their innovations. Different states have different priorities and strategies to accomplish the goals of reform. While Massachusetts, for example, focused on expanding coverage with an individual mandate to purchase health insurance, Wisconsin started simplifying and building on existing public health programs to expand coverage, says a new report.
In the world of state health reform, Vermont often plays the Jan to Massachusetts' Marcia. However, preliminary evaluations suggest that other states and policymakers would do well not to ignore New England's favorite middle child. My colleague previously wrote about Vermont's most recent legislative action on health reform passed in May of 2006. Now, a study published by the Robert Wood Johnson Foundation this week updates us on Vermont's achievements. Here are some of the successes from the Year 1 Interim Report:
Hawaii is a popular destination for anyone seeking sun, sand, surf, or even volcanoes. It's also a top spot for affordable health care coverage.
As The New York Times reported this weekend, Hawaii has the lowest Medicare costs per beneficiary and is tied with North Dakota for the nation's lowest health care premiums. People in Hawaii also tend to live longer than those elsewhere in the United States. As we've mentioned before, Hawaii ranks as one of the top states when looking at health indicators that represent health care access, quality, costs, prevention and treatment, equity and health outcomes.
There are many different theories as to what causes relative health and longevity in Hawaii's population. April Donahue, executive director of the Hawaii Medical Association, told American Medical News Hawaii's population typically has a healthy diet. The Times interviewed a number of doctors and hospitals, and found answers ranging from an active population to a significant military presence to dominance by just a few non-profit insurers in the market.
Earlier this week, we looked at insurance coverage on a state by state (or more precisely -- district by district) level. Based on a similar concept, the Commonwealth Fund report, Aiming Higher: Results from a State Scorecard on Health System Performance, 2009, looks at how well -- or poorly -- states are performing on health care. The report looks at a number of indicators that represent health care access, quality, costs, and health outcomes; this includes avoidable hospitalizations, healthy lifestyles (like not smoking), and preventative care, such as routine checkups and screenings.
We've written often about misaligned incentives in the US health care system -- we pay for quantity of care instead of paying for quality. We've seen high-performing health systems across the nation work to reverse this trend -- and succeed in bringing down costs and improving quality. It is possible for the U.S. health care system to become a value-based purchaser, to move toward pay for performance (healthier patients getting the right treatment at the right time) rather than fee for service (paying for more and more tests and procedures, regardless of whether or not they help the patient). So we're glad to see states taking steps toward pay for performance by including it in their Medicaid contracts.
We're always looking for real-life examples of low-cost, high-quality care. Minnesota is a good place to look, and the state's largest health plan is a good place to start. Patrick Geraghty, CEO of Blue Cross Blue Shield of Minnesota, took part in a NIHCM health policy forum in Washington this summer and presented the "Minnesota Experience." He suggested that the nation's leaders embrace the Minnesota model -- because it works.
"The discussion we are having as a nation is really not just about health care but it's about health. Wellness, prevention, and quality outcomes is really what we are collectively thinking about," Geraghty said. Positioning itself as a "health" -- as opposed to a "health care" -- company, Geraghty described BCBS's effective, "disruptive innovation" model for delivering care. Steps he called for include:
We all know you can earn rewards for frequent flying. But what about for routine trips to your doctor?
Emphasizing primary care and preventive services is a key goal of health reform and many contend the savings from such programs can help finance a health care overhaul (and make us a healthier country). Yet, the details of how these savings might be realized are less clear.
Indiana is one state to find some answers. Contributing to a statewide effort to improve population health, Managed Health Services, one of three Medicaid plan administrators in Indiana, now offers the CentAccount Healthy Rewards Program. Participants accrue dollars on a CentAccount Mastercard debit card as a bonus for participating in appropriate preventive care services -- in the appropriate care settings. LIke the doctor's office, not the E.R.
With Congress on its summer break, it seems like a good time to take a look at what's going on in Massachusetts. The state is covering 97 percent of its people. Costs remain a challenge -- but Massachusetts is moving diligently and creatively toward solutions.
The New York Times noted in an editorial this Sunday:
Massachusetts' experiment in universal health coverage has become a favorite whipping boy for opponents of health care reform. They claim the program is a fiscal disaster and that the whole country will be plunged into similar disaster if President Obama and Congress' s Democratic leaders have their way.
That is an egregious misreading of what is happening in Massachusetts. The state's experience so far suggests that it is more than possible to insure almost all citizens, and stay within planned budgets -- although it will take great creativity and political will to hold down risings costs so that the program is sustainable.