Here’s a cake recipe for the Health Policy Commission

WHEN MASS GENERAL Brigham submitted its performance improvement plan on May 16, I thought what was proposed was “wholly inadequate.”

In recent days, to follow up that comment, I tried to write a commentary explaining my position. My first draft read a bit wonkish, using references to CHIA and Total Medical Expense and Alternative Payment Mechanisms. I found myself alluding to Health Policy Commission “decision criteria” and “attribution rules” for which contracts they include when assessing unadjusted spending by a primary care physician group, etc.

I had written a lot of words to try to make this simple point: that the proposed $70 million a year revenue reduction offered by Mass General Brigham was inadequate to address the full extent of the above-benchmark spending that the hospital system causes through its high and ever-growing commercial prices.

Part of the confusion is that when the Health Policy Commission arrived at its determination that Mass General Brigham is spending at a level $50 million above the state benchmark per year, that estimate was only for a portion of the hospital system’s total commercial spending.  It isn’t that the Health Policy Commission erred—it is just that they are limited in their analysis for projecting over-the-benchmark spending.  High and growing prices and related spending for hospital services are not part of the commission’s review unless they are connected to contracts where the system’s primary care physicians are the attributed providers under rules established by CHIA, the Center for Health Information and Analysis.

When Mass General Brigham decided to focus its plan  on cutting spending solely tied to those contracts that the Health Policy Commission used in its analysis—and actually promised $70 million in savings—I worried that the hospital system was pulling a fast one. While it appeared the hospital system was cutting spending more than it needed to, the reality is it was cutting too little.

It’s a complicated situation, one that I’ll try to simplify in somewhat unorthodox fashion.

Think of Mass General Brigham as a baker who bakes cakes for a living. The hospital has a great reputation for its cakes, but it is also known for baking very salty cakes.

Assume that the hospital system adds two teaspoons of salt to every cake it makes and sells.

For quality control purposes, assume that a laboratory (run by the Health Policy Commission) is asked to do an ingredient analysis by taking one-quarter piece of the entire cake and analyzing it for its salt content. The analysis reveals that the cake slice contains 1/2 teaspoon of salt when the standard for all cakes is that such a slice should not have more than 1/4 teaspoon of salt; so it is essentially twice that level in this piece.

With that finding, the Health Policy Commission lab tells the Mass General Brigham baker that the cake recipe needs to change. The baker is put on a performance improvement plan, which basically requires him to address the excessive salt issue.

The baker knows his cakes have high salt content, but he also knows he sells more bottled water (a side business) if he keeps his cakes on the salty side. Taste tests have shown that Mass General Brigham’s bottled water is no different or better than tap water, even though it costs $5 a bottle.

Mass General Brigham comes up with a performance improvement plan that reduces the amount of salt in the recipe by a quarter teaspoon. Instead of a recipe using 2 teaspoons of salt, it will use 1 ¾ teaspoons.

But that recipe doesn’t really address the salt problem.  A real solution would think about the salt content of the whole cake, not just the slice. A recipe addressing the overall salt problem would remove a full teaspoon of salt, leaving only 1 teaspoon on the list of ingredients.

The Health Policy Commission should reject Mass General Brigham’s new recipe and insist on one that really addresses the saltiness problem in the whole cake.

That is what ought to happen next Wednesday when the Health Policy Commission meets to review Mass General Brigham’s performance improvement plan.

Paul A. Hattis is a fellow at the Lown Institute.