Unmanaged care

Costs are up and quality is in question. Is there a doctor in the house?

LAST SUMMER, AFTER 17 years as CEO of Tufts Health Plan, Harris Berman traded in the rough-and-tumble life of an HMO executive for the quieter confines of academia. But as he settles into his new post as chairman of the department of family medicine and community health at Tufts University School of Medicine, the 66-year-old infectious-disease physician has plenty of bumps and bruises from his years in the health care industry trenches. “I felt pretty beat up the last half of the ’90s, with all this managed care bashing,” says Berman. “I get to be one of the good guys now.” Then he adds,”I thought we were then, too.”

Berman and other pioneers of the managed care movement thought of themselves as forward-looking social innovators, designing a system for comprehensive health care delivery that ensured that patients got all the care they needed, but not more than they needed. In the health care tumult of the 1990s, however, HMOs were unmistakably cast as the bad guys.

Denying care for vital services. Relentlessly focusing on the bottom line. Bean-counters ruling over doctors. In the end, the managed care revolution proved about as popular as a prostate exam. The anti-managed-care backlash that swept the country in the late 1990s stripped away many of the restrictions on access to care and specialists. Most patients were allowed to see almost any doctor in their area and receive care at any hospital. “Utilization review” and “prior authorization,” the much reviled terms for the approval needed for certain services or prescription drugs, were cast aside, while patients’ “bill of rights” laws were enacted to give consumers leverage against health maintenance plans.

These changes were the systemic response to the rallying cry of patients and providers—”put health care back in the hands of doctors.” That solution, however, turns out to have come with a not-insignificant catch: The doctors have no idea what they’re doing.

That may be overstating the case, but not by much. Increasingly, we are coming to realize that medicine is characterized by a split personality. On the one hand, the rapid pace of advances in care and technology has brought with it life-saving procedures and drugs, plus new tools to diagnose conditions with unbelievable precision. But the system for delivery of that cutting-edge care is a disorganized, often chaotic world of misaligned incentives, information systems that leave patients vulnerable to potentially harmful errors, and endless bureaucracy. As a result, for nearly every patient who receives the gift of a miracle breakthrough in modern medicine, there is one who fails to get the most basic treatment needed to control routine conditions.

“The rate at which health care produces really serious defects would drive a for-profit business out of town in about six months,” says Mark Chassin, chairman of the department of health policy at Mt. Sinai School of Medicine in New York and a leader in the movement to bring quality improvements to US health care. “Quality is really, really mediocre, across the board, so simply putting the care back into the hands of the doctors won’t do the trick.”

It’s not that doctors don’t know what the best care is—although that, at times, may be part of the problem. Rather, the system for delivering and paying for health services is structured in a way that, at best, impedes quality care and, at worst, actually rewards substandard levels of care. Hospitals and doctors reap no gain for keeping patients healthy, and if patients require further care or hospitalization because they weren’t treated optimally to begin with, providers simply bill insurance companies again. Meanwhile, patients seeking the best care have no clue as to the quality of care provided by a particular clinician or hospital beyond the word of family, friends, and neighborhoods.

Dr. Rushika Fernandopulle
has an improved model.

“We know more about the people who work on our cars than we do the people who work on our bodies,” says William Van Faasen, chief executive of Blue Cross Blue Shield of Massachusetts, the state’s largest health plan.

We shouldn’t be surprised at that, or at the shortcomings of the care we receive. “Every system is perfectly designed to give you the results it is currently giving you,” says Dr. Thomas Lee, president of the physicians network at Partners HealthCare, the parent organization that runs Massachusetts General Hospital and Brigham and Women’s Hospital.

Recognition that the results generated by the system are far from optimal is fueling a new revolution in US health care. If the revolution has a manifesto, it is a 2001 report from the Institute of Medicine, a Washington, DC-based nonprofit research group. Crossing the Quality Chasm: A New Health System for the 21st Century calls for a redesign of the system for delivering and paying for care so that patients have information on the performance of physicians and hospitals, and so that providers can tap information technology to coordinate care and rid the system of huge inefficiencies.

Transforming the tradition-bound world of medicine into a well-oiled 21st century industry won’t be easy. But with health care awash in expensive, new cutting-edge treatments, drugs, and medical devices, the imperative for change is growing. And the effort to tackle huge problems in the care delivery system is taking place alongside a parallel cost crisis of at-least-equal magnitude, one that is also being fueled by the ever-expanding array of medical treatments. Soaring health care premiums are swamping government payers, private employers, and US workers, while pushing coverage even farther out of the grasp of the 44 million Americans with no health insurance.

HMO blues

The backlash against managed care in the late ’90s had as its target the cost-cutting imperatives that patients and doctors felt were driving every decision by HMOs. But cost cutting was the furthest thing from Harris Berman’s mind in 1971 when, as an idealistic young doctor fresh out of the Peace Corps, he and a colleague founded the first prepaid health plan in New Hampshire.

“The reason that we did that had nothing to do with it being less expensive,” says Berman. “What we offered was actually considerably more expensive than Blue Cross, but it had much better coverage.” That coverage included annual physicals, “well baby” visits, prescription drugs, and other services that distinguished the new health maintenance organizations from the traditional coverage then offered by large indemnity insurers like Blue Cross, which mainly paid for hospital care. Though the new model was initially more expensive, Berman and other HMO pioneers were banking on the idea that their approach ultimately was better for controlling the growth of costs as well as for long-term patient health. “Because we were in organized systems, our rate of inflation wasn’t as high as the rate of inflation of traditional plans like Blue Cross,” says Berman. “And in the late ’70s, what happened is the [cost] lines actually crossed and now we were less expensive.”

“Harris and his colleagues really thought they were part of a social reform movement,” says Nancy Turnbull, a lecturer at the Harvard School of Public Health. “They really thought they were part of an effort to make health care better.”

For years, the HMO movement was viewed exactly in those terms. During the early 1990s, however, as a wave of mergers and plays for market share swept over both the hospital and health insurance industries, the ability of HMOs to win contracts with provider systems at deeply discounted prices made the prepaid plans increasingly attractive to employers, through which most working Americans obtain health coverage. Companies sought to lower their benefit costs by enticing, if not forcing, workers into the growing world of HMOs, complete with its restrictions on where patients could get care.

“The problem was it was a top-down revolution,” says Robert Blendon, a health policy professor at the Harvard School of Public Health. “There was never any buy-in by the physicians and the public, so it had no support beyond the business community when it started restricting services.” What’s more, although the nonprofit Massachusetts HMOs such as Tufts and Harvard Community Health Plan stayed truer to the original managed care mission, nationally the industry developed a reputation for being more concerned with managing costs.

But the problem with breaking free of the managed care shackles is that nobody seems to know what to put in their place, says Paul Ginsburg, president of the Center for Health System Change, a Washington, DC-based, policy research organization. “We didn’t like elements of managed care,” says Ginsburg. “And at the time [in the late 1990s], we felt we were wealthy enough to simply discard them and not worry about what to replace them with.”

Paying the piper

For a while, that no-worry attitude seemed perfectly reasonable. With the economy going gangbusters and hospitals and insurers engaged in a wave of mergers and consolidations to better compete on the increasingly market-driven health care playing field, a price war between payers and providers produced several years with virtually no increases in health care costs. But over the past several years, any thoughts that we could have our health care cake and eat it too have vanished.

Health care inflation has returned with a vengeance. Employers, workers, and health plan administrators are reeling after several years of double-digit premium increases, driven by the rising cost of care as well as the increased utilization of expensive drugs, medical devices, and imaging tests. Health costs for Massachusetts firms employing more than 50 workers increased 37 percent from 2000 to 2003, according to a survey conducted by the state Division of Health Care Finance and Policy, with the price of an average family plan clocking in last year at $818 per month, or nearly $10,000 a year. Health care costs are by far the “number one concern” of Massachusetts employers, dwarfing taxes, workers’ compensation rates, and energy costs, says Rick Lord, president of Associated Industries of Massachusetts. Lord says one employer recently told him that his health care costs alone would equal the total payroll of a facility in Mexico.

Although premiums are expected to rise at a somewhat lower rate this year, the increases will remain far above inflation or wage growth. The federal Centers for Medicare and Medicaid Services estimates that health care costs as a share of the gross domestic product will increase from 14.9 percent in 2002 to 18.4 percent in 2013.

“We are going to test the limits of our willingness to pay for health care,” says Dr. David Blumenthal, director of the Institute for Health Policy at Massachusetts General Hospital. US society is on a course “toward ever increasing consumption of health care resources,” he says. “I don’t think anything is in sight that will fundamentally alter that pattern.”

That prognosis has people like William Conley fretting. As benefits manager at the College of the Holy Cross in Worcester, Conley is responsible for the health care coverage of about 925 employees. “I don’t think anybody out there in their right mind is saying people shouldn’t have adequate health care,” says Conley. “But at what price?”

Holy Cross pays 90 percent of the premium for employees, but the school has upped co-pays for office visits and brand-name drugs in an effort to keep costs in check. In the end, says Conley, workers pay a price for rising health care costs, one way or another. “You only have X amount of dollars to pay for benefits and salary increases, and what you pay in one place you can’t pay in another,” he says.

Holy Cross pays out $8,340 per year to cover an employee with a family health plan. For someone making $20,000, that’s a huge fringe benefit, Conley points out. “But what are you going to do?” he asks. “Not give health care to your lower-paid people?”

That is exactly what some firms have done, by contracting out work such as custodial services to companies that provide less—or no—health insurance to their employees. Holy Cross has been approached by contractors on just that basis, Conley says, but the college has said no. “It is not within our tradition,” he says of the Jesuit school.

Most employers are governed by more earthbound considerations, and the imperative they feel to rein in health care costs is growing. At Specialty Minerals, a North Adams subsidiary of Mineral Technologies (a multinational supplier to manufacturing industries), workers were informed last year that, as of January 1, the firm would no longer provide health care coverage for any employee’s spouse who had insurance available through their own employer. That announcement sent a ripple through the local economy, as the wives and husbands of Specialty Mineral employees went scurrying to their own bosses.

Jeffrey Stevens, vice president for human resources at North Adams Regional Hospital, had six employees married to Specialty Minerals workers come to him to sign up for the hospital’s health plan. Stevens doesn’t knock the company for its decision. “The truth is, it’s breaking a lot of companies,” he says of rising premium costs. Still, when it comes to providing comprehensive family coverage, Stevens worries about employers like his becoming “the last man standing.”

“Limbo land”

One consequence of health care cost pressure is the largely invisible growth of a group of people whose coverage is incomplete. This group, best thought of as “underinsured,” includes families only some of whose members have coverage and those with policies that cover only a portion of routine-care expenses.

“It used to be that you had coverage or you didn’t,” says Becky Derby, policy analyst at Health Care for All, a Boston-based advocacy organization.”Now there really is a third category.”

Mia and Kevin Beal know this new world of underinsurance all too well. The young couple lives in West Yarmouth with their three children. Kevin Beal, 32, works in an auto body shop, which offers no insurance coverage. Mia Beal, 31, was on the verge of landing a job as an administrative assistant in a dental office this spring that would provide coverage for her, but not her family. With 11,000 children on the waiting list for the state’s Children’s Medical Security Plan, she’s been told it could take a year to secure coverage for her own kids. Meanwhile, the Beals are trying to tap the state’s “free care pool” for help with an outstanding bill of $8,000 from Cape Cod Hospital for the delivery of their infant daughter, Ashley, in February.

“You know, the ironic thing is if me and my husband didn’t work, we’d have more rights,” says Mia Beal, alluding to Medicaid coverage for low-income residents, which they earn too much to qualify for. With both parents working, but with neither job providing family health coverage, “you’re in limbo land,” she says. “I’m not super knowledgeable about it, but I do think everyone has the right to go to the doctor and everyone has the right to health care.”

For Nancy Bullett, her coverage woes come with the added insult of being part of the health care world herself. A registered physical therapist who started her own private practice in North Adams three years ago, the 49-year-old single mother of two says her business now clears about $45,000 a year. But with that, the only family health coverage she could afford was a $400-per-month policy from Mid-West National Life Insurance. The plan doesn’t cover annual physicals, and it carries deductibles of $5,000 for hospitalizations and $2,500 for outpatient procedures. Bullett says she could get better coverage from Blue Cross Blue Shield, but that insurer’s”Value Plan” would cost $610 a month, more than she feels she can afford.”It’s another mortgage,” she says.

Obtaining affordable health care coverage has long been a problem for low-income Americans, but that problem is now working its way up the economic ladder. “Working and middle-class people in America are experiencing, for the first time, medical financial insecurity,” says Arnold Milstein, a national health care consultant and executive at Mercer Human Resource Consulting.

Cafeteria care

Indeed, this financial insecurity is also creeping into even the most generous workplace-based health insurance. In the past, with employers picking up the tab for health coverage, most employees gave little thought to the particulars of their plan and whether it made the most sense for them. But the cost pressures of recent years—and the collapse of managed care as the solution—are forcing companies, and their insurers, to rethink the way they cover, and control, their employees’ health care costs.

One new approach is to make employees and their families responsible for paying directly for some portion of their medical costs out of “health savings accounts,” to which they and their employer both contribute. In January, Tufts Health Plan became the first Massachusetts-based insurer to experiment with this method, which has been dubbed “consumer-directed health care.”

The Tufts “Liberty Plan” can be customized by employers, but the basic prototype calls for a health savings account of $600, which the employee draws down for routine doctor visits and other outpatient care. After that sum is exhausted, the worker is on the hook for the next $900 in expenses. If an employee’s health costs exceed the full $1,500 deductible, insurance kicks in to cover the remaining expenses.

The idea is to make the consumer more cost conscious, without discouraging routine and preventative care. Unlike the days when the lion’s share of spending came from hospital care, costs today “are distributed much more broadly in many more small-ticket interactions,” says Jon Kingsdale, senior vice president of Tufts Health Plan. “The only person there all the time is, in fact, the patient, the consumer.”

Dr. Lee: The system is “perfectly designed”
to give us what we’re getting.

Is an $1,800 MRI really necessary to diagnose the cause of a jogger’s knee pain, or might a few $50 physical therapy sessions be worth trying first? That is the type of decision-making the new plans put into the hands of patients, with a strong incentive—their own money—to avoid unnecessary spending. Consumer-directed health plans are designed to “empower the consumer to be a more prudent consumer,” says Kingsdale.

If some herald the plans as an important innovation in the drive toward greater “consumerism” in health care, others see in them the further deterioration of any type of social compact by which there is collective responsibility for the welfare of all. The new consumer-directed plans, say critics, will be appealing to relatively healthy workers who don’t utilize many services, as well as those well-off enough to comfortably handle the out-of-pocket deductible, should the need arise. Lower-income workers or those with lots of medical expenses will be inclined to stick with traditional plans that offer more comprehensive coverage. But if healthier workers opt out of those plans, premiums will rise as the risk pool fills with high-cost patients. This scenario led Stanford University economist Victor Fuchs, writing two years ago in the New England Journal of Medicine, to proclaim consumer-directed health care plans “another nail in the coffin of health insurance as a form of social insurance.”

“It’s like the water table is dropping,” says Catherine Dunham, president of The Access Project, a Boston-based national nonprofit organization that promotes health care access to underserved populations. “There are no risk pools anymore. There are risk puddles.”

Meanwhile, even in traditional health plans, out-of-pocket payments at the point of care, including office visit co-pays and hospitalization deductibles, are rising steeply, passing costs to consumers rather than building them into the share of premiums paid by employers. “We’re going backwards in that once again sicker people are going to be paying more and more for their care,” says Derby, of Health Care for All.

James Robinson, a professor of health economics at the University of California-Berkeley, says that as health insurance becomes more costly, it is exposing an underlying reality. “Healthy people have never benefited from health insurance—because they’re healthy,” he says. “All they need is catastrophic coverage.”

The conundrum, says Robinson, is that it’s probably a good thing for patients to have some financial stake in their health care spending—as long as it’s not too much. “I personally am mixed on it,” Robinson says of the shifting of more costs onto consumers. “It’s a regressive income transfer, and given that I’m a bleeding-heart liberal, I think that’s a bad thing. On the other hand, how are we going to convince Americans that health care is a precious commodity and that you can’t just get it without limits? People do tend to spend more wisely when they’re not spending someone else’s money.”

Care management

No matter whose money is being spent, we’re hardly getting the best bang for our health care buck. The great irony of US health care is that while it may be able to deliver increasingly sophisticated treatments and perform miraculous, life-saving feats of surgical wizardry, it does a remarkably poor job at delivering basic care to treat some of the most common, well-understood conditions. A study published last summer in the New England Journal of Medicine, which examined the medical records of more than 6,000 US adults, found that in only slightly more than half of all cases were patients receiving the appropriate care for common conditions such as asthma, high blood pressure, diabetes, and depression.

Mary Lemire is working hard to be the antidote to that problem. A nurse at Fallon Community Health Plan in Worcester, Lemire keeps in touch by telephone with 150 to 200 Fallon patients who have diabetes, coaching them on everything from proper dietary habits to stress management techniques. If she does her job well, the patients won’t be making as many visits to their doctor or ending up in a hospital bed. “It helps them to remain independent and home with their families, doing the things they like to do,” says Lemire.

And it helps Fallon keep a lid on health care payments. Disease management programs for conditions such as diabetes, asthma, and congestive heart failure are growing rapidly among health plans. They represent the type of”win-win” situation all experts say we should be seeking out—strategies that can promote better health outcomes while also reducing health care costs.

Increasingly sophisticated “predictive modeling” programs allow health plans to not only target patients with individual conditions, but also to identify through claims records those patients with multiple conditions who are at greatest risk for hospitalization—and for consuming lots of health care dollars. “Care management” programs aimed at that small but very high-risk pool of patients have led to a “sustained 50 percent reduction in hospitalizations for these members,” says Dr. Roberta Herman, medical director at Harvard Pilgrim Health Care.

John McDonough, executive director of Health Care For All, says these advances could fulfill the original promise of health maintenance organizations. “This is the promised land,” says McDonough. “It is managed care, but it’s managed care done right.”

But managed care done right may be harder than ever, because the health care delivery system has become more unmanageable. “It’s a much heavier lift now than it was in the old days,” says Charles Baker, the Harvard Pilgrim chief executive.

In the old days, Baker’s company was known as Harvard Community Health Plan, and its members received primary care at a network of clinical centers operated by the health plan and staffed by salaried doctors and nurses. “The delivery system was really the product that people were offering,” says Baker, and that made it relatively easy to implement systematic guidelines for patient care. Today, Harvard Pilgrim and other HMOs are principally insurers, not care providers, and the patients they are targeting in their disease management efforts are being cared for by thousands of physicians in independent, private practices scattered across the region.

“We’re trying to create adherence to evidence-based standards of practice in a delivery system that is far more fragmented and less managed than 10 or 15 or 20 years ago,” says Baker. The disease management programs are an effort by insurers to graft elements of the managed-care ethos back onto a health delivery system that rejected the strictures of HMO-style medicine.

Harvard Pilgrim has also tiptoed back into the minefield of clamping down on excessive utilization of high-cost services, announcing earlier this year that it would require doctors ordering any expensive non-emergency imaging test, such as an MRI or CT scan, to first seek approval from a radiology consulting firm hired by the insurer. Harvard Pilgrim’s spending on advanced imaging tests soared from $45 million in 2001 to $73 million in 2003, and company officials say some of that is going toward cases of routine low-back pain or headaches, for which the expensive scans may not be medically necessary.

Not surprisingly, doctors are not happy with the move. “We’ve gotten a lot of angry calls from members,” says Dr. Thomas Sullivan, president of the Massachusetts Medical Society. “It’s another burden on physicians. It’s a huge hassle.” Though he agrees there may be some unnecessary use of imaging tests, Sullivan says Harvard Pilgrim has brought back a “blunt instrument from the 1980s” in trying to deal with the problem.

Besides, when it comes to reining in unnecessary health care costs, doctors aren’t the only problem. Dr. Ann Loudermilk, an emergency room physician at Caritas Norwood Hospital, says even when she explains that an MRI is not likely to reveal anything that would change the course of treatment, patients sometimes plead for the test to allay their worries. “I call it radiation therapy,” she says.

Performance anxiety

While insurers might have the most obvious stake in keeping their subscribers out of the hospital, provider systems are also showing new interest in bringing sensible, evidence-based care to patients they treat—and a willingness to flex their muscles to do so. For several years, Partners HealthCare has operated a disease management program for patients hospitalized for congestive heart failure in any of its five hospitals. That condition, in which the heart loses pumping power, is the leading cause of hospitalization among those 65 and older, with more than 1 million admissions for the disease annually in the US. But Lee, president of the Partners outpatient network, says the voluntary program was consistently”undersubscribed.” So Partners officials decided that, as of last January,”everyone will go into the program,” unless their treating physician specifically opts out.

But Dr. William Dec, director of clinical cardiology at Massachusetts General Hospital, concedes “there has not been a uniform embracing” of the new policy. The reaction of some doctors, he says, has been “Are you crazy? You’re not taking care of my patient.”

“Doctors are being asked and strongly encouraged—and even forced—to function more as parts of teams that are designed to reliably deliver the best possible care,” counters Lee. “We don’t want to say we’re eroding physicians’ autonomy; we want to say we’re making best practices happen reliably.”

GIC executive director Dolores Mitchell:
“It can’t be business as usual.”

In today’s provider networks, which are as diffuse as they are vast, that’s easier said than done. “Doctors don’t like to be supervised,” says Alan Sager, a professor at Boston University School of Public Health. “They want clinical autonomy and financial autonomy. If they insist on having both, they will have neither.”

Still, there is one way to link clinical with financial outcomes that is starting to shake up the health care landscape. “Pay for performance” is the new watchword, promising financial rewards for providers based not on the number of patients they see, but on the results they achieve. That concept, say some observers, could turn the status quo on its head. “[Now] we don’t pay for quality,” says David Blumenthal of Mass. General’s Institute for Health Policy. “You earn more if you screw up.”

One of the more ambitious pay-for-performance initiatives is being carried out by a group of large employers led by General Electric. The “Bridges to Excellence” program rewards primary care physicians for meeting five standards of good care established by the National Committee for Quality Assurance, a nonprofit organization established in 1990. Physicians must complete surveys reporting, by objective measures, how well they are controlling high blood pressure, diabetes, and other common conditions among their patients. They also must demonstrate that they have established disease registry systems that allow them to identify all patients with particular conditions and systematically apply advances in medical knowledge to their treatment.

Physicians in Massachusetts who meet the NCQA standards are eligible to receive bonuses of $60 for each patient in their practice who is covered by GE, Raytheon, or Verizon. If a doctor cares for 200 patients from those three companies, that translates to a bonus of $12,000—enough of an incentive, say company officials, to spur physicians to work toward meeting the quality standards. Meanwhile, the companies believe their investment will be repaid in higher quality health care and lower insurance claims.”We’re pretty confident we’re going to at least break even, and we think we’ll do better than that,” says Francois de Brantes, director of GE’s health care initiative and chairman of the Bridges to Excellence board of directors.

The rating game

While pay-for-performance initiatives are aimed at driving providers toward improved quality of care through financial incentives, health reformers are also pushing to make data on the performance of hospitals and physicians publicly available. While nearly everyone in health care says such information is needed—and more of it will be coming—there have already been some bumps in the road to transparency.

In March, Blue Cross unveiled a new Web site that rates hospital performance in various areas of treatment. The move immediately created a stir, however, when it was reported that in caring for heart attack patients, four Boston-area community hospitals performed better than did Massachusetts General Hospital, Brigham and Women’s Hospital, and Beth Israel, all of which are world renowned for their cardiac care.

One of the biggest challenges in rating the performance of health care providers is adjusting for differences in the severity of their patients’ conditions. Without such weighting, providers that care for sicker patients will fare worse on such scores. That’s exactly what’s wrong with the heart attack data, says Lee, the Partners network president. In fact, he says, every patient with a severe heart attack who is admitted to Winchester Hospital or Melrose Hospital, two of the hospitals that were ranked above the Partners hospitals, is transferred to Mass. General as a matter of policy. “They’re smart people and they’re well-intentioned people, but their data are far from perfect,” says Lee of the Blue Cross rating gurus.

“The rush to get something out there has overwhelmed the desire for scientific accuracy and meaningful data,” agrees Sullivan, the Mass. Medical Society president.

But Sharon Smith, vice president for health care services at Blue Cross, says there’s good reason to rush. “The reality of having something out there is that people will work toward improvement,” says Smith. “If you didn’t start with something, you wouldn’t get to anything.”

David Blumenthal, of the Institute for Health Policy, says that if providers have problems with the precision of rating data that’s available today, they have only themselves to blame. “We, as providers, have been much too slow to take the lead” in devising measures of quality, he says. As a result, he says, insurers and other reform advocates may think “the only way to get providers to engage is to hit them with a two-by-four.”

The lumber certainly came down in March, when the state’s Group Insurance Commission, which oversees health care benefits for 265,000 state workers, retirees, and family members, announced that its coverage plans will introduce hefty surcharges for choosing care in hospitals or doctor practices that score poorly on a measure of health care efficiency that considers both cost and quality.

“It can’t be business as usual,” says Dolores Mitchell, executive director of the GIC, pointing to the state’s soaring health care costs for workers and retirees, which are approaching $1 billion a year.

The state agreed to different timetables for the various insurers who cover state workers to roll out new performance-based fee schedules. Tufts Health Plan is the first insurer to adopt the changes. Starting in July, all state-covered employees who elect Tufts coverage will pay a $200 co-payment if admitted to a hospital in the plan’s “preferred tier,” based on a combination of cost and quality. Those seeking care at a hospital in the nonpreferred tier will pay a $400 co-pay.

The idea has come up before. Two years ago, the Associated Industries of Massachusetts, an association of large employers, invited a Minnesota company to conduct a feasibility study of implementing just such a tiered system in the Massachusetts health insurance industry, but the plan met with resistance from providers—led by Partners, because its high-cost teaching hospitals wound up in the least-preferred category. Under the Tufts plan, many of the state’s prestigious hospitals once again are placed in the less preferred tier for the three types of services that were rated (adult general care, pediatrics, and obstetrics). The Massachusetts Hospital Association, in a state-ment issued following the announcement of the new state initiative, said it “remained concerned” that the tier system “may not yet be fair to hospitals or reliable for consumers.” But Dr. James Mongan, chief executive of Partners, says he had concerns about the ranking methods used by the Minnesota company but is “supportive of going ahead” with the new state plan.

Berman, the former Tufts Health Plan CEO, calls acceptance of the tier system “a seminal event,” all more significant because it “wasn’t the health plans trying to push this on the providers, it was an employer—in this case the state —saying this is what we want.”

For her part, Mitchell says she felt no choice but to start challenging the status quo. “You can sit here watching that train chugging down the track and the prices getting higher and higher,” she says. “Or say, damn it all, let’s try it a different way and stand outside of the box.”

It’s hard to argue against the idea of making information available to consumers about the performance of health care providers. But some wonder whether that’s really what patients are looking for. It’s one thing to consult the Consumer Reports ratings when shopping for a new washing machine. Looking for a “best buy” when you’re faced with major surgery or an odd-shaped mole that has suddenly appeared on your back is quite another.

“The idea of comparison shopping or being on the Web when you’re being taken to the CCU—I don’t think so,” says Gerald O’Connor of Dartmouth Medical School.

Even the strongest advocates of transparency in health care acknowledge that we could fast be heading toward information overload. Arnold Milstein, the Mercer health care consultant who helped devise the GIC plan, says the ideal would be for these new initiatives to pave the way to a new level of health care quality where patients are not required to think about whether a hospital or doctor is up to snuff.

“Do people just want to leave it to their doctors and nurses? Absolutely,” says Milstein. “The question is, how do you get there? If you had very, very robust pay-for-performance levels, doctors and hospitals would be out of business if they didn’t deliver very high quality care.”

Some see the ultimate goal of the transparency transformation now underway in health care as a system similar to those that oversee industries like commercial aviation. Airline passengers don’t want to be “sorting through a whole lot of data on safety records when they decide whether to buy a ticket from American or United,” says Chassin, the Mt. Sinai Medical Center researcher. “We want to feel someone else has taken care of that. That should be the model we have in health care.”

While there are ample grounds for gloom over the costs of care and the challenge of bringing the fruits of technology and innovation to the health care delivery system, there is some reason to hope that addressing the latter will help to address the former. Wendy Everett, president of the New England Healthcare Institute, a nonprofit health research organization, says waste and inefficiency account for as much as 30 percent of the $1.4 trillion spent nationally on health care, more than enough to provide health coverage for all Americans. But, beyond the Herculean task of wringing such savings from our health care system, directing them toward the coverage of all Americans would involve political decisions that we don’t necessarily seem ready to make.

“All parties have to come to the table with an understanding that even with $50 billion [in Massachusetts health care spending annually], dollars are finite and pathology is infinite,” says BU’s Sager. “How do you make decisions and make tradeoffs? No one is taking responsibility for marshalling the $50 billion-plus that’s available for health care in Massachusetts and making sure that the 6.5 million of us get good care.”

Meet the Author

Michael Jonas

Executive Editor, CommonWealth

About Michael Jonas

Michael Jonas has worked in journalism in Massachusetts since the early 1980s. Before joining the CommonWealth staff in early 2001, he was a contributing writer for the magazine for two years. His cover story in CommonWealth's Fall 1999 issue on Boston youth outreach workers was selected for a PASS (Prevention for a Safer Society) Award from the National Council on Crime and Delinquency.

Michael got his start in journalism at the Dorchester Community News, a community newspaper serving Boston's largest neighborhood, where he covered a range of urban issues. Since the late 1980s, he has been a regular contributor to the Boston Globe. For 15 years he wrote a weekly column on local politics for the Boston Sunday Globe's City Weekly section.

Michael has also worked in broadcast journalism. In 1989, he was a co-producer for "The AIDS Quarterly," a national PBS series produced by WGBH-TV in Boston, and in the early 1990s, he worked as a producer for "Our Times," a weekly magazine program on WHDH-TV (Ch. 7) in Boston.

Michael lives in Dorchester with his wife and their two daughters.

About Michael Jonas

Michael Jonas has worked in journalism in Massachusetts since the early 1980s. Before joining the CommonWealth staff in early 2001, he was a contributing writer for the magazine for two years. His cover story in CommonWealth's Fall 1999 issue on Boston youth outreach workers was selected for a PASS (Prevention for a Safer Society) Award from the National Council on Crime and Delinquency.

Michael got his start in journalism at the Dorchester Community News, a community newspaper serving Boston's largest neighborhood, where he covered a range of urban issues. Since the late 1980s, he has been a regular contributor to the Boston Globe. For 15 years he wrote a weekly column on local politics for the Boston Sunday Globe's City Weekly section.

Michael has also worked in broadcast journalism. In 1989, he was a co-producer for "The AIDS Quarterly," a national PBS series produced by WGBH-TV in Boston, and in the early 1990s, he worked as a producer for "Our Times," a weekly magazine program on WHDH-TV (Ch. 7) in Boston.

Michael lives in Dorchester with his wife and their two daughters.

As for the changes being brought to the system for delivering and paying for health care, they represent “an industrial revolution and a cultural revolution,” says Lee, the Partners HealthCare network president. It will require wholesale change in the way doctors and other providers think about and perform their jobs, the way insurers pay for services, and the way patients receive care. Getting there will be rough, says Lee, but he’s confident the journey will be worth it.

“We are going to cross the quality chasm. We are going to have a safer, better, more efficient health care system by the end of the decade—and it’s going to be brutal, believe me,” he says. “No one who ever lives through a revolution enjoys it.”