Not Running a Hospital: Spotlight shining in MA

Sunday, November 16, 2008

Spotlight shining in MA

For my out-of-town readers, you'll want to check out this story in the Boston Globe that is likely to be the talk of the town here.

23 comments:

Anonymous said...: Wow, nine online pages! Perhaps we are seeing the value of retaining investigative print reporting.

The imbalances revealed in the article emphasize yet again the imperative of rewarding providers who provide good value, defined as clinical outcome per dollar spent. Not until payors (including Medicare) use this yardstick will we begin to see real improvements in both cost and quality of our nation's health care. And the accuracy of measurement tools is now sufficient to justify using this yardstick on a national basis. Let us hope our politicians begin to buy into this concept.
And congrats to Paul and to BIDMC for showing up well on quality of care in the article - it is very validating to your efforts.

nonlocal; November 16, 2008 12:11 PM
liverboy 08 said...: Bravo Team BIDMC & Pres. Paul!
So nice to see result's that the BIDMC "Way" is working, and has been recognized by others without hidden agendas.Keep up the GREAT WORK!; November 16, 2008 6:24 PM
e-Patient Dave said...: I can't say strongly enough how important it is to the care BUYER (and I mean me the patient, even though this industry insists on having contorted definitions of roles) to have access to this information.

I expect there will be loud, angry, and even bellicose retorts and retaliations. I expect those arguments will all revolve around arguments asserting that something's more important than whether the care is getting delivered well, and whether economic efficiency is evolving as processes improve. I disagree.

Let the flames begin, and let the Spotlight shine.; November 16, 2008 7:21 PM
Anonymous said...: This is another classic example of the need for price transparency, at least for all outpatient procedures, routine childbirth, and all elective surgeries that need to be scheduled in advance. Confidentiality agreements that stand in the way of making this information available to both patients and referring doctors need to be abolished, by legislation if necessary.

In the meantime, I don’t know why insurers haven’t moved more aggressively to combat Partner’s aggressive tactics with co-pay tiering for the above mentioned hospital charges. If Partners were placed in a less favorable tier which required a higher patient co-pay, even as low as $500 or so, it might be enough to get patients’ (and their referring doctors) attention. Tiering has worked well to increase utilization of generic drugs at the expense of brand name drugs that are much more expensive but no more effective. I think the same approach could work for hospitals.; November 16, 2008 7:58 PM
Anonymous said...: I think the tone of much of the reaction to this article reminds me of Don Berwick’s "Stages of Dealing with Data" that mirror Kubler-Ross:
1) The data are wrong. ("MGH sees sicker patients....etc.")
2) The data may be right, but they're irrelevant, so there’s really not a problem ("Yeah, these quality measures show that MGH is just average at trivial things like everyday CHF care, but they're not measuring the truly important stuff like the rare and unusual diseases we take care of.")
3) The data may be right, but whatever the problem is, it's not our problem. (It's the Health Plans' fault...or Levy and Baker are conspiring against us and it’s their fault…or whatever.")

Very few organizations (and BIDMC seems to be an exception)seem to be getting to the 4th stage—"The data are right, there’s a problem, and it’s our problem—we all bear some responsibility for this and so let’s fix it."; November 16, 2008 10:19 PM
Anonymous said...: A very interesting story - nice work by the reporters. Now, it will be interesting to see whether the SEIU will pick up on and run with it, and run ads on how Partners has higher rates than everyone else. Probably not. After all, "Eye on MGH" just doesn't have quite the same rhythmic ring to it as "Eye on BI"; November 17, 2008 3:19 AM
John said...: Excerpts for the busy:

#1
Call it the best-kept secret in Massachusetts medicine: Health insurance companies pay a handful of hospitals far more for the same work even when there is no evidence that the higher-priced care produces healthier patients. In fact, sometimes the opposite is true: Massachusetts General Hospital, for example, earns 15 percent more than Beth Israel Deaconess Medical Center for treating heart-failure patients even though government figures show that Beth Israel has for years reported lower patient death rates.

#2
But market forces don't do much for some other highly regarded hospitals. A few years ago, when an executive for Beth Israel Deaconess Medical Center asked then-Tufts HMO boss Harris Berman why Beth Israel, a Harvard teaching hospital, wasn't paid as well as Partners, Berman said he had a simple response: "You are not Partners."

One influential researcher found that Beth Israel's overall mortality rate was lower in 2005 than the mortality rates at both the Brigham and Mass. General, but the hospital and its doctors still earn 15 percent to 20 percent less for the same work, according to the Blue Cross rates obtained by the Globe.

"Shouldn't there be some correlation between what you get paid for doing something and the quality of what you do?" asked Beth Israel chief executive Paul Levy last month in remarks at the Massachusetts Medical Society.

#3
Hospital accreditors faulted Mass. General after a surprise inspection in December 2006. They saw staff members fail to wash their hands after touching patients, and the hospital could not document that its staff had consistently followed routine safety checks that can prevent doctors from performing the wrong procedure on patients. At the Brigham earlier this year, the rate of one common - but dangerous - infection that sometimes enters the bloodstreams of intensive care patients was about twice as high as that at Beth Israel Deaconess. Brigham officials said their infection rate has since dropped.

When it comes to saving lives, the Brigham and Mass. General do not rate the highest even in Massachusetts. A review of 42 individual mortality ratings produced by the state and federal governments for Massachusetts hospitals from 2002 to 2007 found that three other hospitals - Beth Israel Deaconess, Partners' own Newton-Wellesley Hospital, and Beverly Hospital - had the highest average scores.

The mortality rankings - adjusted for the relative sickness of patients at different facilities - graded hospitals as either average, above average, or below average for ailments and procedures from pneumonia to coronary bypass surgery. The vast majority of the ratings for all hospitals were average, but Beth Israel earned a dozen above-average scores, and none below average. The Brigham received seven above-average scores and one below-average score. Beverly and Cape Cod hospitals each earned five top scores and no low scores. Mass. General had four high scores and one low score.

*THUMBS UP TO BIDMC*; November 17, 2008 8:18 AM
Anonymous said...: Lots of blogs have covered this. Here are a few:

http://blogs.wsj.com/health/2008/11/17/prices-vary-widely-at-hospitals-around-boston/#more-3638

http://blog.hcfama.org/?p=1976

http://www.bluemassgroup.com/showDiary.do?diaryId=13999

http://commonhealth.wbur.org/jon-kingsdale/2008/11/its-time-to-get-serious-about-costs-by-jon-kingsdale/#more-944

http://ducknetweb.blogspot.com/2008/11/hospital-branding-is-most-expensive.html

http://ourownsystem.com/2008/11/16/the-disincentives-of-transparency/

http://www.healthcaretwoday.com/2008/11/its-time-for-playing-field-to-be.html

http://managinghealthcarecosts.blogspot.com/2008/11/boston-globe-spotlight-article-on-costs.html

http://universalhub.com/node/21607#comments; November 17, 2008 10:40 AM
Anonymous said...: Paul - While I agree that Partners is overpaid and is a monopoly, would we be hearing from you if you hadn't broken up the CareGroup PSN and were getting the same rates as Partners? You had the same market share that would have forced any of the local insurers to match Partners' rates and you broke it up and are now complaining about the results. Partners should be broken up as a monopoly that got together to drive prices higher but, again, CareGroup was very similar and you were the biggest force that broke that entity up.; November 17, 2008 11:11 AM
Anonymous said...: The PSN was a contracting disaster that had to be ended. BTW, it was not close to the same market share as Partners.

But, please, for once, understand that I am not complaining about Partners. I am complaining about the fact that rates are not related to the quality of care. That is a very different point. Listen again to my comments at the MMS meeting. A podcast is available on their website -- http://massmed.typepad.com/mms_podcasts/; November 17, 2008 11:35 AM
Anonymous said...: Partners' role as a marketplace bully is the consequence of Scott Harshbarger's blatantly anti-competitive decision, as Attorney General in the 1990s, to approve the merger of MGH and the Brigham.; November 17, 2008 11:38 AM
Anonymous said...: Finally some substantive reporting from the town's paper of record. For years those in the trenches have noted the gross disparities in payments derived from the market clout of 800 pound gorilla. Now that the truth is out regarding the lack of correlation to quality of care, what courageous insurer will take the first step toward a remedy that rewards quality and punishes poor performance? If the reactions in the Globe piece are predictive, don't bet on BC/BS!; November 17, 2008 12:09 PM
Anonymous said...: Paul - The CareGroup PSN had Beth Israel Deaconess, Glover, Nashoba, NE Baptist, Mt. Auburn, Bridgewater Park, Lahey Clinic... and Waltham, Affiliated Pediatrics and Southboro for different periods of time. Although maybe not the same size as Partners, I doubt any local insurer would be willing to exclude all of these providers from their network. Further, if your quality of care is better and you are still complaining then your issue is in fact about Partners getting paid more. Otherwise you would be quietly content knowing your quality of care is better. Are you honestly saying that the PSN and such a huge market share were not able to get better rates than BIDMC on their own? The whole reason for Partners was to create an entity to put a gun to the insurers head for higher rates.... you had a similar entity and you broke it up.; November 17, 2008 12:29 PM
Anonymous said...: Regarding the issue of Partners becoming big enough to put a gun to the insurers' heads, please be assured that this behavior is not localized to Boston. In my large metropolitan area (hint; it contains 1700 Pennsylvania Ave.), there is one hospital system which has effectively cornered the market in one of the adjacent states by acquiring all but one of the hospitals in the region. It has done the same thing with the insurers as Partners, although it is politically smart enough to keep the details from becoming public.
What started out as a legitimate effort to gain bargaining power with insurers has morphed into several regional/national powerhouses controlling the market in their areas and beyond. Until they are forced to compete on more than size (see my comment above on the definition of value), this wasteful situation will continue nationwide and eventually break all our pocketbooks. Boston, look beyond your narrow borders and parochial disputes!

nonlocal MD; November 17, 2008 1:56 PM
Anonymous said...: I don't know how I can better make the distinction than I have made between the shoe you are trying to shoehorn me into and the one I am already wearing. Please listen to the podcast, where I make the point about payments to ALL hospitals and how it would be very nice if those payments were somehow related to the quality of service offered.

The PSN was not an integrated healthcare delivery system. It was a contracting group, and that's all. It did not have a unified purpose or a coherent strategic vision among the participants. Therefore, it was not effective as a contracting group. Perhaps it might have been with a unified corporate structure, but that structure did not exist, and the parties had no interest in creating same.

HBS Dean MacArthur and others involved in creating PHS had a thughtful business model and they executed it well. Mr. Connors made that point in the article. The question for today is whether PHS contributes value to society commensurate with its relatively higher rates. If so, then there is nothing to talk about. If not, then there is an important debate about what would work better. Higher rates for all? Rates based upon actual performance? You name it and make the case for what you believe in.

But whatever you think, shouldn't it matter that virtually all of the MA entities involved in this arena (hospitals and insurers) are non-profits, subject to supervision by the state? That their underlying individual and joint purpose should be to provide the best quality and safety of patient care at the overall lowest cost to society? That public officials have a legitimate right and obligation to see how well that is being carried out? And that the Globe writes about it if they think it is newsworthy and in the public interest?

For my part, this is not carping about PHS or any other health care provider in the state. It is about how we thread the needle of affordability and quality over the coming decade.; November 17, 2008 1:59 PM
Anonymous said...: Obviously, my reply was to anon 12:29, not nonlocal...; November 17, 2008 2:01 PM
Anonymous said...: It's an old story line: the neighborhood bully finally gets what's coming to him. Trying to determine who knifed Partners in the back is like trying to solve Murder on the Orient Express. There are lots of suspects and motives.; November 17, 2008 3:58 PM
Anonymous said...: Partners deserved this. They are not at all clinically integrated and they have no better outcomes than anyone else yet demand more pay because of their name recognition. How do they even justify negotiating as one network when they are not clinically integrated? If we had a DA with any spine they would have looked into this Partners monopoly a long time ago. Ads on the radio recently with Mass General and Brigham & Womens going after the same cardiac care patients... that is not clinically integrated and I would bet you have chiefs of every service at both facilities. PCHI the contracting entity is simply the vehicle that Partners uses to get more and more of an unfair share of healthcare dollars from the local insurers. Even if they have migrated to a single EHR that has not been in place since when they came together and had zero integration to allow them to contract together. This article should have come out years ago and should be followed by authorities looking into this "network" and their legal ability to contract together.; November 17, 2008 4:51 PM
Anonymous said...: Meanwhile, this notice was published today. A coincidence?

QUALITY AND COST COUNCIL: The Health Care Quality and Cost Council meets. According to Health and Human Services Secretary JudyAnn Bigby, who chairs the council, members will vote on a launch date for the council’s much delayed consumer website. The website, which will display comparative cost and quality information on health care services, has been plagued by two years of delays. Business groups decried Gov. Patrick’s midyear budget cut of the council, saying the website was weeks away from launching. The cut led the council, created by the 2006 health care reform law and charged with ensuring health care quality and controlling costs, to lay off its staff and transfer some operations to the Division of Health Care Finance and Policy. (Wednesday, 1 pm, One Ashburton Place, 21st floor, Boston); November 17, 2008 6:38 PM
Anonymous said...: good question, methi, whether the SEIU will pick up on this and start running ads during ball games about how Partners has higher rates than everyone else and doesn't share the wealth with employees.

anyone besides me wondering if there's a connection between partners and SEIU? back-door funding or anything?

curious that of all the hospitals in boston this one would be picked as the target.

well let's see what SEIU has to say about it.; November 17, 2008 10:29 PM
shadowfax said...: I don't live or work on the East Coast, so I maybe don't get it. To me this read like a straightforward hit piece on Partners by the insurance companies. (Who do you think leaked that data to the Globe?)

Paul, I see where you are coming from with regard to quality, so I'm not getting on you here. But if all the other hospitals in the area are losing money ("Caritas Christi had to borrow money this year to pay for basics, like oxygen tanks.") and only through aggressive marketing is Partners able to achieve a positive but sub-average operating margin, why is Partners the bad guy?

Seems to me the bad guys are the insurers who underpay when they can get away with it (and the feds who underpay everybody).

And the Globe reporters are gullible.

I went into more detail at Movin' Meat. Tell me why I am wrong.; November 18, 2008 2:05 AM
Anonymous said...: Not for me to tell you! There are lots of ways to interpret the story. See, for example, my reply above to anon 12:29.; November 18, 2008 5:43 AM
Anonymous said...: Barry,

Maybe one of the reasons why insurers don't develop tiered networks is that some of the biggest and most expensive hosptials--you can guess which ones refuse to participate in such contracts.

Government has an important role to play in fixing this problem, since the retreat of government helped to create it, as the Globe story concludes:

"...The resulting wide range of payments for the same services reflects a healthcare system in which deregulation and lax government oversight have allowed the hospitals with the most clout to extract big increases from insurers while everyone else falls behind…....”

This is a national problem, as one person noted, and it requires a reengagement by government and the creation of new models of government involvement and oversight. Ironically, Boston is one of the more competitive hospital markets in the country but the size and influence of Partners, particularly on the physician side, means competition cannot work by itself. Time will tell if we have the political resolve and smarts to fix this.; November 19, 2008 9:25 AM