We need CBO-like scoring of state health care bills

WHEN I WAS A MEMBER of the Massachusetts House of Representatives back in the 1990s, I learned about the concept of continuous quality improvement, or CQI, as a way to improve any process – including medical care – using a rigorous data driven approach. CQI seemed good to me and a natural fit in my job because legislators are always seeking to improve things – big, medium, and small – and to keep at it depending on the issue’s importance.

So, in light of the Massachusetts Legislature’s inability to agree on important and challenging health care reform legislation at the wrap-up of their biennial 2017-18 session, I offer this proposal for a legislative process improvement: Before adopting any major health legislation, not including appropriations bills, the House and Senate should submit their bills for an impact analysis by the Massachusetts Health Policy Commission for their timely review and public reporting.

The health care legislation that had been adopted last December by the Senate and this past June by the House included many meritorious and timely provisions, including new consumer protections against “surprise billing” by health care providers, telemedicine, drug pricing transparency, authorization for “dental therapists,” and more.

Both proposals also sought to address a long-standing issue involving deep disparities in reimbursements to large and powerful hospital systems such as Partners HealthCare versus payments to smaller and less powerful community hospitals in Brockton, Holyoke, and other disadvantaged communities. For at least a decade, community hospitals and others, including two attorneys general — Martha Coakley and Maura Healey – and a special legislative commission, have urged that action be taken to support community hospitals and to level the uneven playing field.

The Senate and House bills both sought to bolster community hospitals, though in markedly different ways, including big financial hits on large hospitals, insurers, retail clinics, and others. Key stakeholders, including businesses, insurers, and others, objected to the potential impacts of these bills, particularly their likelihood to sharply increase health care spending, something the state has been battling, with success, since the passage of the 2012 law creating the Health Policy Commission.

If anyone wanted to find a balanced and independent analysis of the impact of the House or Senate bills, good luck. None existed. And it’s not because there was not enough time. Gov. Charlie Baker kicked off the process in early 2017 with a package of proposals that included changes to MassHealth, the state’s Medicaid program. The Senate discarded nearly all of the governor’s proposals, and put forward its own bill in December; the House waited until June 2018 to advance its own plan.

That left lots of time for thoughtful and serious analysis. But the House and Senate, whose leaders seem to respect and appreciate the Health Policy Commission for their thoughtful and perceptive reports – including analyses of proposed hospital consolidations, most recently of the Lahey Health and Beth Israel Deaconess led merger – chose to treat the commission like the Maytag repairman: When the phone doesn’t ring, you know it’s the Legislature.

We have, of course, a credible and time-tested model for this kind of analysis on the federal level called the Congressional Budget Office. The CBO has operated since 1975 and produces expert and valued analyses of proposed federal legislation moving through Congress. Particularly relating to health policy, CBO reports frame policy discussions in real terms, including dollars, covered lives, and other impacts in an inherently uncertain and volatile forecasting environment.

I suggest that in their adoption of joint rules for the 2019-20 legislative session, the House and Senate include that any major health legislation produced by either the House or Senate should be “scored” by the Health Policy Commission shortly after engrossment in each chamber and that any final compromise bill be scored before enactment by either legislative branch.

Some will say, why just health care legislation? That is valid. I suggest that health care is deviously complex, important, costly, and notoriously prone to unintended consequences. A benchmark analysis would help legislators, the administration, interest groups, and citizens to understand the consequences of major system changes. Perhaps a dollar threshold could be set in annual system impact, say $50 million, for bills to be scored and the Legislature could send other bills at its discretion.

In the spirit of continuous improvement, this could be a test for the establishment of an entity to undertake similar scoring and analyses for non-health related legislation, depending on the results of this experiment.

The lack of clarity about the impact of significant and controversial legislation does not serve state government or the public well. While the Legislature seeks to impose transparency requirements on others, it could serve the public interest by imposing some on itself.

John E. McDonough is a professor of practice at the Harvard T.H. Chan School of Public Health and was a member of the Massachusetts House from 1985 to 1997.