Hattis criticism of DPH off the mark

Agency focused on cost-benefit, not just costs

THE CRITICISM of the Department of Public Health that was recently published in Commonwealth may have struck a nerve, but it fell far wide of the mark.

The article, “DPH needs to stop being a paper tiger,” was written by Paul Hattis, a former commissioner of the Health Policy Commission. He recommends that the Legislature transfer the responsibility of approving or denying certain health care provider capital, bed, and service expansion projects from DPH to the Health Policy Commission. I disagree with his recommendation. He fails to explain the differences in the roles of the two agencies and believe that the DPH, through its commissioner, senior staff, and the Public Health Council, does indeed have the skills, expertise, and commitment to take on tough health care issues.

My understanding of the differences in the roles of the two agencies stems from my 12 years of experience as a member of the Public Health Council as well as years spent as an emergency physician and health care leader and administrator. The regulatory process has been developed so that, for the type of projects identified in the Hattis article, the Health Policy Commission has an important role to provide DPH and the Public Health Council with substantive comments that are to be considered in the DPH review and decision-making process.

The Health Policy Commission was created by the Legislature in 2012 with a mission to control health care cost growth. The commission produces an annual cost trends report and sets an annual target for cost growth that providers must abide by or face sanctions. The commission has the primary responsibility to review many transactions between health care providers for cost and market impact, and it issues periodic reports on various subjects chosen by their staff, described in their website “as part of our cost-control efforts.”

What’s wrong with that? Nothing, if one bears in mind that the commission’s focus is only on the cost side of the ledger. Cost analysis is a very different thing than cost-benefit analysis, which attempts to quantify the benefits of spending as well as costs.

Costs are relatively easy to count. Costs are a linear and cumulative compilation of money spent.

Benefits, on the other hand, are often more difficult to quantify: it’s far more complicated to put a monetary number on a longer life, a life improved by access to appropriate care, a life with less pain, or a renewed ability to engage in physical activity after a joint replacement. It is far more complicated to measure in monetary terms the value of simply being alive compared to the alternative.

In contrast to the Health Policy Commission, DPH’s fundamental mission is to promote the health of Massachusetts residents. DPH pursues its missions in multiple ways: promoting vaccines, anti-smoking efforts, coordinating responses to specific health threats, and regulating hospitals, nursing homes, clinics, labs, etc. to ensure quality and access to care and much more.

In 2020, DPH and the Public Health Council led the way in helping the Commonwealth meet the COVID-19 pandemic head-on and DPH worked tirelessly to assist health care providers in their efforts to combat the pandemic. DPH continues to play this role and we are all better because of it.

DPH also rules on significant health care provider construction, bed, and service expansion projects through a process known as determination of need. Determination of need is a balanced analysis of both costs and benefits, evaluating projects based on the health care and public health needs of patients. As indicated above, cost analyses are part of the process with substantive input from the Health Policy Commission and, when needed, DPH chooses an outside economist to perform an independent cost analysis, the expense of which is borne by the provider.

In 2017, the DPH determination of review process was significantly strengthened to provide improved tools to review significant health care provider projects. The Public Health Council, which has final decision-making authority with respect to determination of need projects, will review the staff recommendations and, if voting to approve a project, can decide to impose additional requirements or oversight to ensure that the DPH goals of improving access to care and public health value are addressed.

The 2021 version of the determination of need process is designed to help ensure that heath care providers undertake projects that address pressing public health needs, are quality driven, and as cost effective as possible

DPH has aggressively directed providers to address societal issues that are beyond the Health Policy Commission’s purview. The Health Policy Commission does not look at access to care issues. DPH’s regulatory arm has directed health care providers to develop creative access-to-care initiatives and programs to improve the public health of those most in need of assistance. DPH, through its determination of need process, is actively addressing issues such as food insecurity, language barriers, access to primary care, access to behavioral health and substance use services, the availability of training programs for low-income individuals, and methods of addressing other issues related to the social determinants of health. The burden of proof is on the project proponent, and it requires extensive documentation of the project’s public health value and economic benefit before allowing the project to move forward.

As part of DPH’s aggressive efforts to improve access to care and improve public health, the determination of need program requires a set-aside of 5 percent of total project costs for community health initiatives which are likely to focus on behavioral health needs, access to care, the opioid crisis, nutrition programs, and other social determinants of health.

Meet the Author

Alan Woodward

Doctor, Former chief of emergency services at Emerson Hospital and former member of Public Health Council
DPH and the Public Health Council have the requisite expertise and resources to determine if the projects are needed or not. As previously stated, DPH’s overall mission is to improve public health. This is what the DPH determination of Nned program is all about, increasing access to needed services in a cost-effective manner. DPH and the Public Health Council perform important roles in the health care system and its future. These roles should be preserved and, if necessary, improved, not dismantled.

Dr. Alan Woodward was a member of the Public Health Council from 2007 to 2019 and was chief of emergency services at Emerson Hospital for 18 years, from 1989 to 2007. He was also president of the Massachusetts Medical Society from 2004 to 2005.