Health Policy Commission should do more

Agency should listen more and weigh ballot question evidence

THE 2012 LAW CREATING the Massachusetts Health Policy Commission (HPC) includes a provision setting up an advisory council to the executive director of the commission.  The charge to the advisory council is to “advise on the overall operation and policy of the commission.”  There are about 30 or so people drawn from various health care system stakeholder groups currently on the advisory council, including me.

The council has often tended to focus its discussion with the Executive director on substantive health policy issues in the state connected to healthcare spending:   What are the cost drivers and the factors behind them?  When HPC staff have created focused reports on provider price variation, out-of-network pricing, or pharmaceutical spending—advisory council conversation has sometimes been focused on policy solutions, or what should HPC try to study in order to further explore a particular challenge.

What was interesting about this past week’s advisory council meeting was a discussion that was more focused on the operational responsibilities of the HPC.  The commission is an independent and somewhat unique state agency that is charged with trying to help keep health care spending growth in check at both a systems level as well as for the ultimate purchasers of care (families and businesses). Should it have some responsibility to use its competence, even when that is primarily a convening or clarifying evidence-sort-of-operational role, to help advance health policy decisions in the state with an aim of making them more informed and robust?

Many of us at the meeting expressed a desire to want HPC to take on these sort of responsibilities even though (and perhaps especially because) some number of important health policy decisions will need to be made by others—be it the Legislature, other government agencies, or even voters.

Two very attention-grabbing and potentially high consequential events which could impact health care affordability in our state are on the decision-making horizon for this year.

One is already officially before the HPC. The agency is currently completing a cost and market impact review of the proposed Beth Israel-Lahey et al transaction.  If completed, this would be the second-largest merger in our state’s history.   The other issue is the proposed ballot initiative that would mandate nurse staffing ratios in caring for patients at our state’s hospitals; an initiative that is on track to go before voters this November.

In both cases, I think the commissioners will need in the next month or so to make a decision about an appropriate process role for the agency, which would move the commission into new operating territory.  I am hopeful it will choose to do so in both situations.

To date, the commission has primarily limited itself to only making assertions about the impacts of a transaction.  For the most part, the agency has focused on using some well-grounded data and analytic techniques to support their observations and projections tied to future commercial spending growth, provider pricing, or market share changes which could result from a proposed transaction.

The agency’s analyses and commentary have tended to be somewhat limited when assessing transactional impacts on competitors or communities that could also be affected by a proposed acquisition or project.  And the agency has tended to avoid making any substantive recommendations about how best to mitigate any harms that it has identified in its reviews. Instead, it has signaled its anxiety by either making a referral to the attorney general’s office or by providing a copy of its report to the Department of Public Health for its consideration.

In the completed cost and market impact reviews to date, HPC has noted in its reports having had interactions with other market stakeholders.  In some instances, the agency has obtained views and analyses from competitor provider organizations as well as comments and data from the state’s commercial health insurers.  But to my knowledge HPC efforts to formally obtain outside stakeholder views end with the issuing of the preliminary cost and market impact review. To date, the agency’s operational process has not afforded any formal opportunity for other key stakeholders to react on the record to the commission’s preliminary findings or to the reactions of the parties proposing the transaction.

For me, the proposed BI-Lahey et al transaction calls out for a bit more public discussion about the cost and market impact review findings.  And HPC needs to create a process to make that happen.

Specifically, I think the HPC, after it has issued its preliminary market impact report and obtained the comments about it from the transacting parties of BI-Lahey et al, it should have a brief period of soliciting written commentary.   Anyone from the public would be free to submit a written response.  Hopefully some number of informed stakeholders may want to share their reflections on the findings and arguments of the HPC and the transacting parties

After receiving these responses, the HPC should then consider holding a public hearing and ask for direct testimony from a limited number of respondents who filed written comments. The goal of such a hearing would be to afford the commissioners the opportunity to gain additional perspective before issuing a final report. Presumably this would be a limited group, who in their written submissions have some relevant data and evidence to discuss which is responsive to the report’s findings.

The purpose of such a hearing would not be simply to ask people to come and share their feelings about whether the proposed merger is a good or bad idea. My hope is that at a minimum the public testimony session would include testimony from our state’s commercial health insurers.  Our commercial health insurers are in the best position to offer evidenced-based commentary on what they project could happen should this proposed transaction be approved.  Their experience in price negotiation, insurance plan design for limited or tiered network products, and their ability to project the impact of the merger on commercial spending and market dynamics make them a critical group to hear from directly.

The value of this expanded written testimony and public hearing would not only benefit the HPC in its preparation of the final report, but also provide valuable perspectives and information for use by the office of the attorney general and the Department of Public Health, the two agencies that hold the real regulatory power over the approval, or the placing of  conditions on the transaction.

The second issue—the nurse staffing ratio ballot initiative—is one that could have significant financial and operational consequence for our state’s hospital industry.  It could also have significant impact on our residents’ commercial health insurance premiums.  Admittedly, the ballot initiative is a highly charged political issue where nurses unions will be defending the ballot proposal and the hospital industry will be leading the charge in opposition.

The HPC should put out a report providing commentary on the evidence presented by the two sides. There’s a lot to analyze, including the impact of nurse staffing levels on quality of patient care, nurse burnout and depression, hospital operating expenses, insurance premiums, and total health care spending.

With this sort of ballot initiative, which is highly political in nature, it would be inappropriate for the HPC as an independent government agency to take a position either for or against it. Rather, I think their role would be to write a narrative report, parsing out the validity of evidence that both sides cite in their arguments, as well as rate the strength of that evidence.

Meet the Author

Paul A. Hattis

Associate professor, Tufts University Medical School
From where I sit, with a strong desire to see that our state’s health care system move to a more affordable place, I can’t think of two better ways for the HPC to carry out its important mission on our behalf during the next six months.

Dr. Paul A. Hattis is an associate professor of public health and community medicine at Tufts University School of Medicine. He is a former member of the Health Policy Commission and a current member of the commission’s advisory council.