In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Rebecca Katz.
This profile was published in the December, 2014 issue of HealthLeaders magazine.
"The food that we eat is critical. It has to be not just nutrition. It has to be translated to the plate."
Master chef Rebecca Katz's quest to change the American diet started with a life-altering event: Soon after the Californian finished culinary school in 1999, her father began a battle with laryngeal cancer.
"I went back east to cook for him, and I didn't know how to cook for someone with cancer," she says. "There was nothing to guide me. I realized how helpless I felt. My father became my guinea pig."
The process of culinary experimentation during her dad's treatment and recovery led to the publication of Katz's first book, One Bite at a Time, in 2004—and convinced her that food is a key element in cancer care.
The secret sauce of cooking for cancer patients is "understanding their transient taste changes as they go through treatment," Katz says. "The nerve endings are affected by chemotherapy and radiation. Look at your palate like a switchboard, and you're always having brownouts."
Over the past decade, a host of scientific studies have verified the nutritional benefits of several whole foods, herbs, and spices, such as anti-inflammatory effects. Katz found, for example, that carrot and ginger soup is a great dish for many cancer patients undergoing head and neck radiation therapy. "Their taste buds are on fire. Almost anything they eat is just too acute."
She says preparing palatable meals for cancer patients is crucial to their treatment and recovery, particularly when temperamental taste buds turn favorite foods foul. "If something doesn't taste good, or the expectation isn't met, you'll push food away."
In 2000, Katz cooked for her first group of cancer patients for a week. "It was the most rewarding experience I have had in a kitchen—to see how the act of food could bring joy into people's eyes." Now, she teaches cooking techniques to oncologists. "It's quite an enlightening experience for doctors," she says. "They can look at their patients with a different eye to see why their patients don't eat."
Now that she's seen how food can positively influence cancer care, Katz is promoting "sustainable nourishment" as a way to fundamentally improve American health. "It's looking at food and cooking food in a way that's delicious and nutritious—food you like and cooking you like. It's not just a diet, it's a way you live your life."
She says sustainable nourishment needs to rise to the forefront of efforts aimed at containing a growing tsunami of chronic illnesses in the United States, including heart disease, cancer, and diabetes. Many people suffering with chronic illnesses are hopelessly noncompliant with doctors' dietary recommendations because they aren't aware of the savory alternatives to their forbidden favorite foods.
When she teaches cooking to people with chronic illnesses or their caregivers, Katz says she never speaks about food in terms of the "can have" and "can't have" lists that doctors give their patients. "This is what I say: 'Here are the restrictions, here is what's going on, here's what we can do so you don't feel deprived.' You have to navigate different foods in different ways."
Katz says there's no excuse for the vast majority of Americans not to eat healthy, delicious food that fends off disease and helps heal the sick. "You'll have people who say they can't afford to eat healthy. Dollar for dollar, I can take you through the grocery store and prove that's not true."
A major component of sustainable nourishment involves encouraging Americans to return to eating whole foods, fruits and vegetables, rather than industrially processed food with high sugar and fat content, she says. "We used to be a community of producers—growing our own food. Now we're a community of consumers. … We have to go back in time to when food was considered important. The food that we eat is critical. It has to be not just nutrition. It has to be translated to the plate."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Otis Brawley, MD .
This profile was published in the December, 2014 issue of HealthLeaders magazine.
Regardless of personal cost, some Americans find it impossible to remain silent when they believe the country is careening toward disaster.
Otis Brawley, MD, chief medical officer of the American Cancer Society and author of a scathing book on what ails U.S. medicine, has no fear of acting as a lightning rod in the ongoing storm of healthcare reform. The 55-year-old has the ability to speak damning truths to powerful healthcare stakeholders, for which he credits his parents, a parochial school education, and the violence-plagued streets of his childhood in Detroit.
"I was one of the few black males in my neighborhood to make it to the age of 35," Brawley says. "I think I just have a strong moral compass. … I see the path this country is going down, and it's bad. We're going to bring the economy of the country down with healthcare, of all things."
One of the central premises of the oncologist's 2012 book, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America, is that the growing cost of U.S. healthcare is a recipe for an economic calamity. If the 20-year trend of increased spending continues, medical services will swallow 35% of the U.S. economy, Brawley says. "That is not sustainable. We cannot exist in the United States if we're spending one-third of our dollars on healthcare."
Brawley is a leader in the field of health disparities research. His views on uneven access to healthcare services in America are both idealistic and pragmatic. "There is basic healthcare that every human being has a fundamental right to," he says, insisting that a combination of technology and cost-effective delivery of primary care and preventive medical services is possible even for people living in poor, remote areas of the country.
"We have this mind-set that the more medicine we consume, the better off we are. There is harm in that."
"Not only do we have disparities in healthcare, we have disparities in preventive care," he adds, noting the level of health education in the general public is woefully short of where it needs to be for people to appreciate the value of their health. "There are a whole lot of people who don't understand health."
Prevention is sharply undervalued, Brawley says. "Nixon declared war on cancer in 1971. Our investments in cancer research have been better applied in Europe. We're irrational. We have this mind-set that the more medicine we consume, the better off we are. There is harm in that. Overconsumption can be incredibly harmful. Our healthcare system is designed to treat people. There's very little in our system that's designed to prevent disease."
He notes that European physicians' emphasis on prevention is paying huge dividends in lower obesity rates, better exercise habits, and other lifestyle-linked health factors. "We give them a diagnosis, then we treat them for that illness," he says of the American doctor-patient relationship. "In Europe, doctors get paid to consciously help people from getting sick. … We don't pay and reimburse for prevention. We pay for treatment. Preventive services need to be appreciated more."
Brawley has several stern prescriptions to improve the status of American health. First is to promote cost-effective screening techniques, particularly among underserved populations. "At $30, stool blood testing is just as effective as colonoscopy, which costs $3,000 per procedure. Let's get some poor folks some stool test kits," he says. But at the same time, disease screening must be deployed judiciously to avoid false positives and unnecessary treatments, including potentially dangerous surgical procedures: "People just don't understand how screening might not be good for them."
In addition, "high caloric intake, lack of exercise, and obesity" are fundamental challenges to American health. Brawley says obesity has been identified as a cause of a dozen cancers and is a particularly vexing problem: "It complicates treatment of all other illnesses."
Lastly, he calls for increasing daily servings of fruits and vegetables, walking at least four hours per week, and quitting smoking.
"A truly informed consumer would be very, very helpful," Brawley says. "The problem is the people who think they are informed about healthcare who are not."
With reform efforts transforming the healthcare industry across the country, health plans are finding ways to branch out beyond their historic roots.
Opportunities for innovation and investment dominate the constructive responses to revolutionary change in any market.
A rendition of Highmark's new sleep store
As insurance carriers adapt to dramatic change in the healthcare industry, longtime players are adopting a range of innovation and investment strategies.
On the entrepreneurial side of the spectrum, Pittsburgh-based Highmark Inc. is looking for gaps in the healthcare consumer market and seizing opportunities as they are discovered. Three years ago, the Blue Cross Blue Shield affiliate built a business innovation and development team to assess healthcare investment opportunities. The business innovation team has launched two new ventures so far, most recently a retail sleep medicine business.
Highmark Dreams of Growth Beyond Insurance
Paul Puopolo, VP of business innovation and development for Highmark, told me last month that the changing healthcare marketplace is opening avenues for growth. "The healthcare industry is clearly changing due to the rapid advancement in technology and changing consumer expectations. This means we need to look at health differently and find solutions and services that impact a consumer's lifestyle—ultimately, their overall well-being—and not just provide insurance. The purpose of Highmark's business innovation team is to look at a variety of trends and consumer needs to create new services and products to bring to market."
On the philosophical side of the investment spectrum, Portland, OR-based Cambia Health Solutions, which started one of the country's first health plans nearly a century ago, views gaps in the evolution of value-oriented medicine as openings for new business lines.
Rob Coppedge, SVP for strategic investment at Cambia, says the company has embraced healthcare innovation as an organization. "We have to take cost out and create a healthcare model that focuses on the consumer experience," he told me recently. "This is a mantra out of the songbook that we all sing from."
Cambia features four health insurance businesses as well as two dozen wholly or partially owned healthcare ventures. The subsidiary businesses have been developed through a "transformative investment" strategy, Coppedge says. "We need to be doing more than the insurance products. We have to make a difference in the healthcare world… We're investing in companies that are transforming the system to change the game."
Cambia seeks investment opportunities that generate economic benefits while filling gaps in the evolving value-based healthcare marketplace. "We certainly see the diversification benefit. That's not lost on us," Coppedge says, "but you can diversify away from something or toward something. We need to have more tools in our toolbox that help transform the system in the new world."
He says Cambia is "getting a twofer" from its investments: It is capitalizing economically and philosophically. "We've turned down lots of investment opportunities because they didn't support our core and our mission." Specifically, Cambia looks for a handful of qualities in its subsidiary partners, including an "investible" business model, innovations that reduce costs and improve customer experience, and a committed leadership team.
Transformational investing requires patience, Coppedge says, noting that Cambia expects market changes linked to the growth of value-based healthcare to play out over the next decade. "It's the sort of goal that you push for over a long time."
Lively's Medical Alert Device
For 2015, Cambia is excited about two growth areas: "retail enablement" and senior services. In the retail sector, Coppedge cites Portland-based HealthSparq as a potential game-changer in the price transparency field.
In senior services, technology-driven companies such as San Francisco-based Lively Inc. have the potential to help revolutionize care for a population that poses a cost challenge for all healthcare stakeholders, he says. Lively is marketing a watch-like monitoring and medical alert device to help seniors with chronic conditions live at home for as long as possible. "No senior wants to wear a badge that essentially says, 'I'm old and frail," Coppedge says of Lively's first-generation "life-line" devices.
Conventional models of senior care come at a cost that is prohibitive while creating what he describes as a "horrible experience" for consumers. "We can't warehouse people in high-cost settings," Coppedge says.
Cambia is generating "positive early results" in transformative investing, but the company is braced for the long haul. "You never know; investing in early-stage companies is a high-risk venture," Coppedge told me. "In the early innings of this ballgame, we feel very good about our chances."
CVS Health has upped the ante in its bid to become a major player in the healthcare provider field by investing heavily in two digital innovation facilities.
Brian Tilzer
Chief Digital Officer, CVS
With about 7,600 pharmacies nationwide equipped with nearly 1,000 walk-in MinuteClinics, Woonsocket, RI-based CVS Health is now building up the company's health IT muscle.
Brian Tilzer, chief digital officer at CVS, says a Digital Experience Center recently opened in Woonsocket and a Digital Innovation Lab set to open this winter in Boston are developing a range of health IT capabilities.
"CVS Health sits at the crossroads between retail and healthcare, so this space is a natural fit for us," he said last week. "We have been laser-focused on digital innovation for years. We are uniquely positioned as a pharmacy innovation company that is integrating pharmacy and retail store experiences… We're hearing directly from our customers that they're looking to leverage digital technology as an extension of the in-store experiences as well as to help manage their health."
He cites a couple a health IT innovations CVS recently introduced at its pharmacies as examples. "[One] of our latest tools [is] our Drug Interaction Checker, which allows users to simply scan over-the-counter product bar codes to check for potential negative interactions with the prescriptions and medications they are taking.
CVS has technological experience and a trove of data, Tilzer says.
"We're constantly working to invent things… We have a unique set of assets that no other company in the healthcare or retail space has, given we are the only player that has a national retail pharmacy, retail clinics, a mail-order pharmacy and pharmacy benefits manager division, and specialty pharmacy services all under one corporation… We also have 17 years of experience and data from our ExtraCare program, the gold standard in the industry, which means we know our customers."
HIT Talent Recruiting
"As we continue to grow the digital team, recruiting remains a top area of focus for us," Tilzer says. "We believe that by having a strong presence in both Boston and at our headquarters in Woonsocket, we can attract top talent in both healthcare and technology throughout New England."
"Our team at CVS Health is continuing to grow, both through the opening of the Digital Innovation Lab in Boston, which can seat 100 and will be made up of 90% new hires, as well as at our headquarters in Woonsocket, where we have a wide variety of job openings as well."
HIT is generating benefits for CVS and its customers Tilzer says.
"We approach digital innovation with an eye toward creating tools that help… customers manage their medications, adhere to prescribed therapies and take care of their health more easily. We are making a real impact and also transforming the role a retail pharmacy like ours can play."
Timely HIT Infusion
A technology infusion is timely for MinuteClinic, says Thomas Charland, who worked as SVP of business and development at the Minnesota-based retail clinics before CVS acquired the franchise in 2006. CVS has since established dozens of MinuteClinic affiliation pacts with hospitals and health systems across the country, and establishing digital communication with these new partners is a top priority, he says.
A primary goal is gaining the ability to "pass records back-and-forth in a secure manner," Charland says. "It's a major initiative. MinuteClinic, in particular, is working really hard on this."
MinuteClinic took a major digital step earlier this year, adopting Verona, WI-based Epic as the electronic medical record system for the retail clinics. "That's a big hospital EMR. It's not flexible or nimble," he says. "It has a lot to do with Big Data… They are measuring pretty much about everything they can."
MinuteClinic and its walk-in retail clinic competitors at Walgreens, Target and Walmart are ripe for health IT innovation, says Charland, who turned to building urgent care clinics in 2007, founding and leading Minneapolis-based Merchant Medicine.
For example, retail clinics could benefit greatly from using telemedicine for "load-balancing of providers," he says, citing the seasonality of most walk-in clinics, which are busiest during the cold- and influenza-heavy months of the year.
He cites the Boston area, where MinuteClinic has facilities in three dozen pharmacies, as the kind of market ripe for load-balancing. "They could lower staff in some locations and connect to the clinics that have nurse practitioners," Charland says. "We're going to see that in urgent care and the retail clinics."
Queue management such as sending time-sensitive text alerts to patients is another hotbed of digital innovation for retail clinics, he says. "You know exactly where you are and when to show up."
A 'Technology-Enabled Healthcare Ecosystem'
Jerry Kolosky, a health IT consultant and former VP at Salt Lake City-based 3M Health Information Solutions, says CVS is poised to become a major healthcare provider player.
"Major retail pharmacy chains such as CVS are well-positioned to leverage ubiquitous national networks of established retail locations; deep, positive customer relationships; and gold-standard brand equity in the health and wellness space to accelerate a fundamental movement, already well under way, in the direction of innovative new modes of primary care delivery," he says.
Kolosky says CVS appears to be carving out a niche in the health IT sector.
"Well-established retail organizations such as CVS can provide a physical platform for new modes of care delivery, beginning with primary care and evolving over time to chronic care management, and to support a network that enables the secure delivery of relevant, actionable healthcare information across settings of care," he says.
"Meanwhile, tiny innovators, supported as required by public and private funding sources, are free to create the edge devices, such as wearable monitors, communications devices, and analytical algorithms that facilitate the optimization of the user experience and power the analytic engines."
CVS is riding a digital wave in healthcare, Kolosky says. "The future of care delivery will be based upon the creation and continuous evolution of a technology-enabled healthcare ecosystem. Such an ecosystem, or 'platform,' will potentiate new, innovative modes of care delivery supported by secure, networked technologies, user experience optimization, and technical-workflow interoperability across the continuum of care."
"Retail health clinics and other physical locations such as senior centers have begun to emerge as physical nodes of care in this embryonic connected care ecosystem," he says.
The Medicare Advantage star ratings program is already risk-adjusted for clinical factors such as comorbidities. Now federal officials are considering adjusting the quality rating program based on beneficiary income levels.
Under pressure from healthcare industry stakeholders and Congress, federal officials are considering making adjustments to the Medicare Advantage star rating program for quality and bonus payments to reflect the impact of socioeconomic status.
In early September, the Centers for Medicare & Medicaid Services requested comments on whether the MA star rating program should be risked-adjusted for SES. The focus of the federal agency is on dual-eligible beneficiaries: low-income individuals who are eligible for both Medicare and Medicaid services. "CMS seeks analyses and research that demonstrate that dual status causeslower MA … quality measure scores," agency officials said in the "request for information" document.
In August, the National Quality Forum, which vets quality measures for healthcare payers, issued a report calling for reforms that account for SES. The organization had previously resisted changes to quality measures to account for the impact of SES, but announced a change of course last month.
"NQF's Board approved a change in its current policy to allow for SES risk adjusting of some appropriate performance measures during a robust, two-year trial. The results of the trial will guide NQF on whether to make this policy change permanent. To be launched on January 1, 2015, the trial will be directed by the soon-to-be-formed NQF Disparities Standing Committee," NQF officials said in a statement.
The organization already accounts for clinical factors in quality measures and says "growing evidence shows that socioeconomic status and other demographic factors may also influence patient outcomes."
In an interview last week, an NQF official said any adjustment to the set of measures in the MA star rating program should be carefully calibrated. "The outcome measures are more likely to be appropriate for adjustment," said Ann Greiner, the organization's VP of public affairs. "This is not a blanket recommendation to adjust all stars measures."
Joyce Chan
Assistant VP of Clinical Performance, Healthfirst
MA Plans Under Star Rating Pressure
New York-based Healthfirst Inc. has firsthand knowledge of the challenge of achieving MA star rating success while serving dual-eligible beneficiaries.
"It becomes a very vicious cycle," says Joyce Chan, assistant VP of clinical performance at Healthfirst.
MA health plans that have a high percentage of dual-eligible members face a "double whammy," she says, because it is difficult to cross the 4-star threshold that garners the highest bonus payments. "You don't get the quality bonus money… then services get cut. The members are the ones that suffer."
Healthfirst has posted a 4-star MA quality rating for the 2015 plan year, but it was a struggle for several reasons:
Cultural diversity: 53% of Healthfirst's MA beneficiaries speak English as a second language
Education level: 70% of beneficiaries have less than a high school education
Poverty and crime rates: The majority of beneficiaries reside in neighborhoods with nearly one-third of residents living in poverty
Physician gap: 66% of beneficiaries live neighborhoods federally designated as health professional shortage areas
The statistics are linked to concrete MA star rating challenges such as dietary restrictions for diabetics conflicting with cultural norms. "Telling a Chinese plan member not to eat rice is really hard," Chan says.
Healthfirst favors a two-stage approach to factoring SES into the MA star ratings. "Risk-adjusting is the appropriate long-term solution, but it will take time to establish the adjustment model," she says.
In the meantime, Healthfirst wants CMS to adopt other options such as the federal agency's value-based purchasing model for hospitals. Under the purchasing model, hospitals are rewarded for year-to-year improvement or achievement of set performance standards. "It's a great interim solution, but it's hard to sustain improvement year after year after year," Chan says.
CMS Feels Star Rating Heat
Members of Congress are pressuring CMS to adjust the MA star rating program to reflect the challenges of serving dual-eligible beneficiaries.
Four bipartisan House members—Rep. Diane Black, (R-TN), Rep. Earl Blumenauer, (D-OR), Rep. Cathy McMorris Rogers, (R-WA), and Rep. Mike Thompson, (D-CA)—wrote a letter to CMS Administrator Marilyn Tavenner on Nov. 14, urging her to act:
"The MA program plays an important role in helping 16 million beneficiaries access high-quality health care, including delivering coordinated care to dually-eligible beneficiaries and other low-income seniors who often experience higher rates of chronic illness, disability and mental illness."
"It is well established that social determinants of health, including socioeconomic status, are important drivers of health outcomes. Dually-eligible individuals are amongst Medicare and Medicaid's most vulnerable beneficiaries and those most in need of the additional benefits and services, care management, and coordination across providers that MA offers. We are, therefore, concerned that the current MA quality and resultant payment system does not capture the social determinants of health that these beneficiaries may face."
Health plans are definitely concerned.
On Nov. 3, Jeff Myers, president and CEO of Medicaid Health Plans of America, expressed his MA star rating misgivings in a letter to CMS Deputy Administrator Sean Cavanaugh.
"Unfortunately, current Star quality measures do not adequately take into account the significant issues that low socioeconomic status has upon the achievement of favorable and preferred health outcomes as well as adverse impact upon plan performance," Myers wrote.
He cited a study conducted from 2011 to 2014 by America's Health Insurance Plans, showing that "plans with greater than 50% enrollment of low-income beneficiaries achieve lower Star ratings than plans that enroll less than 50% of low-income beneficiaries. It also finds that this disparity is growing overtime. Health plans that serve a higher percentage of low-income beneficiaries achieve Star ratings that were found to be 0.5 stars less than plans that serve fewer low-income beneficiaries."
Medicare Watchdog on Alert
Officials at the New York-based Medicare Rights Center are resisting the push to adjust the MA star rating program for SES. "To our knowledge, there is no data proving a causal link between disadvantaged populations and lower plan quality scores," says Krystal Scott, the advocacy group's New York State policy director.
Scott says CMS needs to tread carefully as the agency weighs adjusting the MA star ratings for SES. "Dually eligible beneficiaries may well have health needs that are different from healthier, higher-income populations. Yet, this does not necessarily mean they are more difficult to serve—only that their service needs may be different from other populations. Further, there is data suggesting that dually eligible beneficiaries are more likely to receive poor quality care, but the data do not show that this substandard care is caused by the actions or circumstances of these patients."
CMS has options beyond adjusting the MA star ratings, Scott says.
"We would like to see CMS ensure that appropriate tools are used to encourage high-quality plans to enter and remain in the market to serve dually eligible beneficiaries. Another option would be to compare health plans with similar proportions of low-income patients to each other, rather than comparing them to all Medicare Advantage plans."
CMS is reviewing public comments and could announce a policy proposal as early as February.
Healthcare provider claims that mergers boost efficiencies are drawing intense scrutiny from regulators and provoking a market challenge from payers.
Old habits are hard to break.
One of the goals of the federally led drive to create a value-based healthcare industry is to increase cooperation between major stakeholders. As a wave of healthcare provider consolidation sweeps across the country, the new age of cooperation between providers and payers is starting to look a lot like the old age of adversarial relationships.
An antitrust case in Idaho is one of the hottest fronts in the ongoing cold war between providers and payers. This week in Portland, OR, a three-member panel of the US Court of Appeals for the Ninth Circuit heard oral arguments on a challenge to a federal judge's rejection of a merger deal featuring Boise-based St. Luke's Health System.
In January, the chief judge of the US District Court in Idaho ruled St. Luke's acquisition of the state's largest independent physicians practice, Nampa-based Saltzer Medical Group, violated antitrust law. Chief Judge B. Lynn Winmill ordered St. Luke's to "fully divest itself of Saltzer's physicians and assets."
In an amicus brief filed at the US Court of Appeals, attorneys for America's Health Insurance Plans, the national health plan trade association, delivered a scalding criticism of the St. Luke's merger:
Gerard Wedig, PhD
"An important issue before this Court is whether claimed clinical integration justifies the anti-competitive acquisition of a medical group by a hospital with an already significant medical group. The district court correctly required [St. Luke's and Saltzer] to show merger-specific efficiencies. Instead, [St. Luke's and Saltzer] made claims of clinical integration efficiencies and suggested that the policy goals of the Affordable Care Act overrode antitrust concerns. Those assertions are wrong."
AHIP attorneys claim the St. Luke's merger is unnecessary because healthcare efficiencies are best achieved through negotiations between payers and providers. "The efficiencies suggested by [St. Luke's and Saltzer] are being achieved through relationships between health plans and providers—in other words through market innovation—without the need for anti-competitive mergers by hospitals and providers."
A decision is expected sometime next year.
Provider-Payer Arms Race
In an interview this week, an associate professor at the University of Rochester's Simon Business School said healthcare provider consolidation is sparking a new adversarial struggle with payers. Gerard Wedig, PhD, said mergers are a "natural reaction" among providers as they seek to ensure their survival in a time of rapid change in the healthcare industry.
The main benefit of these mergers is a "stronger provider organization," but health plans are dusting off their health maintenance organization playbooks as a way to offset the surge in health system market power. Selective contracting through so-called narrow networks "seems to be coming back," Wedig said.
"Many provider mergers are based on the idea that insurers won't exclude a large health system," he said. "If you can get people to a point where they can accept a narrow network, then insurers can leave out a large health system."
Employers and consumers are reaching that point, Wedig said, noting that large employers are seeking to control costs in group insurance plans and individual consumers face the growing prevalence of high-deductible health coverage.
"Narrow networks are entirely consistent with consumers having more skin in the game," he said. "Sure, these health systems merge, but you may see them having to compete in a way that they haven't had to in the past."
ACOs Getting Antitrust Pass Earlier this week, the St. Luke's case was a hot topic during a webinar on provider consolidation hosted by Berkeley, CA-based Catalyst for Payment Reform.
One of the webinar's presenters, Carnegie Melon University Professor Martin Gaynor, said the contested St. Luke's merger "illustrates the issues that could arise in an ACO case."
Gaynor, a former director of the Federal Trade Commission's Bureau of Economics, said there have been no antitrust lawsuits involving accountable care organizations—yet. "The concern is whether ACO stands for Anticompetitive Organization," he quipped.
Gaynor said three of the objections that the FTC raised in the St. Luke's antitrust lawsuit could be applied in an ACO antitrust case:
St. Luke's ran afoul of antitrust law because the health system's physician groups were in direct competition with Saltzer physicians.
St. Luke's and Saltzer made claims about achieving healthcare efficiencies that were "plausible but speculative" such as the benefit of sharing an electronic medical record system.
The US District Court in Idaho found the efficiencies St. Luke's and Saltzer claimed were not "merger-specific" and could be achieved through other means that did not risk creating anticompetitive market conditions.
Wedig said ACOs are likely getting an antitrust pass—for now. "It's clearly a model of healthcare delivery that's under the Affordable Care Act that holds some promise," he said. "There's been some effort to get providers to sign on to ACOs. We're trying to nurture them to some degree to see whether they can help reduce healthcare costs. You can see why [regulators] would have some sympathy for ACOs."
Merger Mania Grips Nation
During the CPR webinar, legal officials from California and Pennsylvania said the pace of provider consolidation – and antitrust reviews – is quickening across the country.
Kathleen Foote, senior assistant attorney general at the California Department of Justice, said the National Association of Attorneys General has noted a significant uptick in provider consolidation deals.
She said there were AG representatives from 38 states at a recent NAAG meeting and 27 states reported they were reviewing healthcare industry transactions, including physician group mergers and M&A deals between hospitals and physician groups. "In every location, virtually, this is a topic of great significance," she said.
Tracy Wertz, who serves as deputy attorney general in Pennsylvania, said The Keystone State is experiencing a spike in healthcare provider mergers. "We see more and more healthcare cases... currently, we have eight healthcare transactions before our office," she said.
In past years, the Pennsylvania AG rarely had more than one or two provider merger cases to review.
Data Key Factor for Regulators
In an interview before this week's CPR webinar, the organization's executive director said the combination of nationwide healthcare reform efforts and provider consolidation is a potent mix. "We're really entering into unknown territory," Suzanne Delbanco said.
She said a key healthcare provider consolidation hurdle for state officials across the country is amassing sufficient data to assess merger deals.
The data challenge is two-fold. First, variation of state data resources poses a major antitrust enforcement obstacle. Second, several recent provider consolidation efforts have crossed state lines.
"Some of this consolidation that's happening now is not traditional. There really isn't a history of market analysis to examine the impact of multi-state consolidation," Delbanco said.
Healthcare organizations are discovering untapped value in providing mental health and substance abuse services to super-utilizers of medical services.
Health plans are starting to focus on finding and engaging hard-to-serve beneficiaries who have been falling through the healthcare industry's cracks for decades.
"We're increasingly aware of the impact of behavioral health conditions, whether they are mental health or substance abuse, on physical health issues," Ian Shaffer, executive medical director at New York-based Healthfirst Inc., told me recently.
A mountain of evidence, demonstrating that behavioral health conditions are a major driver of healthcare costs, is accumulating.
In a study of 2 million Medicare Advantage beneficiaries released last month, Bowie, MD-based Inovalon reported data showing that a range of mental health conditions inflate hospital readmission rates. The readmission rates for MA beneficiaries was:
15.5% overall
23.8% for those with anxiety
26% for those with schizophrenia
The report's lead author, Christie Teigland, PhD, wants federal officials to consider including behavioral health in MA's risk-adjustment factors. "They already adjust risk factors for age because older beneficiaries are more likely to end up back in the hospital. Our research shows mental health issues also increase the risk of ending up back in the hospital," she told me.
Red Ink
The CEO of Boston-based Commonwealth Care Alliance (CCA) says the legacy of de-institutionalizing behavioral health is splashing red ink on the Medicare budget and health plan balance sheets.
"For 40 years, we've underfunded the community capacity to care for these people," Robert Master, MD, says, noting that there is a nationwide shortage of community-based respite and transitional housing facilities for individuals with mental illness. "In some cases, they're not ready to be thrown out of the hospital… What is missing is the appropriate gradient of facilities."
Master says state governments have struggled to rise to the behavioral health challenge. "There is so much competition for state tax dollars. What you're doing is cost shifting to the federal government. Medicare pays for that hospitalization."
CCA has 16,000 enrollees, with severe mental illness or substance abuse conditions afflicting 2,000 beneficiaries. The staff at CCA, which Medicare classifies as a Fully Integrated Dual Eligible Special Needs Plan, views the organization as a "care delivery system" that has adopted reducing psychiatric hospitalizations as a core mission.
Master says the vast majority of people with behavioral health or substance abuse conditions do not need to be in a hospital, where Medicare pays $1,100 per day for a bed and psychiatric services. "Most would be better served in a community-based, lower-cost setting."
Transitional Housing 'Just the First Step'
To reduce costs and improve quality of care, CCA is stepping in where de-institutionalization of behavioral health left off. "We have to create the capacities that are missing," Master says.
Last month, CCA started leasing a "mothballed ward" at Carney Hospital in the Dorchester neighborhood of Boston to provide transitional housing for beneficiaries after their release from psychiatric hospitals. It immediately filled the 10 beds and plans to open at least three more similar facilities over the next year.
The transitional housing unit has living room and kitchen space, and "referrals come from the enrollees' own physicians," Master says. But "This doesn't solve the problem. This is just the first step."
Elsewhere, Shaffer says Healthfirst is tackling behavioral health through a new approach to primary care medicine. "Healthcare is a team sport now. We really need to look at it as a team effort to be effective."
Healthfirst is encouraging primary care practices to incorporate behavioral health screening and referrals into their workflow. "It's all driven around the concept of integrating all the services people need," he says.
"We need to get away from primary care physicians either spending two hours with a challenging patient or not spending any time… The [best] intervention may well be encouraging that individual to stick with the appropriate treatment."
Shaffer says the healthcare industry is "reaching a tipping point" on behavioral health. "We're learning more. We tended to bifurcate mental health services and kept them separate from physical health services. Now we're adding them back in."
Reaching Out to Engage Beneficiaries
Owings Mills, MD-based Integra ServiceConnect is also thinking outside the historical parameters of the healthcare box to help health plans engage beneficiaries who have behavioral health conditions.
"We start with the notion that [there is] a small number of people who are driving a large amount of healthcare services," Integra President and CEO Michael Yuhas says. "You need to be able to connect with people on their level."
One of the key ingredients in Integra's secret sauce is community coordinators who find and engage health plan beneficiaries where they live, which is often in disadvantaged neighborhoods.
"This is not a healthcare intervention we're talking about," Yuhas told me. "We've been taught historically that when something breaks, you bring the patient in to fix it. But once you find [a beneficiary with a behavioral health condition], that's not enough. You have to engage them. You have to let them know you're friend and not foe. We've created a science of finding people, engaging them, and connecting them to the services they need."
Integra looks for a set of qualities when it hires community coordinators, few of which are directly related to traditional healthcare industry skills. "It's in their fabric to help people," Yuhas says. Community coordinators live in the areas they serve and are persistent, compassionate, street smart, and resourceful. "We look for people who won't give up. We look for people who are just creative."
I asked whether someone like the rapper and actor Tracy "Ice-T" Marrow, known for his resourcefulness, would make a good community coordinator. "We'd hire Ice-T if we could, but we hire people who know where Ice-T is. We hire people who can find community ambassadors," Yuhas told me. "Mostly, it's the notion of not giving up. We connect with the people others have given up on."
Covering the Basics
Another ingredient in Integra's secret sauce is strictly business-related.
The company helps health plan beneficiaries meet basic needs, which the healthcare industry has long considered insignificant. A change in mindset is long overdue.
"We contract with our clients as a vendor, not as a clinical provider of care… We get paid on the basis of a monthly fee to make sure the member's needs are being met," Yuhas says. This kind of work "doesn't lend itself to the typical billing code."
For example, community coordinators have taken health plan beneficiaries to consignment shops to buy coats to stave off the chill of winter and hospitalizations linked to exposure. "When we buy a coat, we don't bill for a coat."
Yuhas says Integra's efforts are "life-changing" for many health plan members: "We're working with members who are not accustomed with people coming out into their neighborhoods and actually helping them."
As the second open enrollment period for health insurance exchanges kicks off, carriers face a range of challenges, from ongoing information technology woes, which may affect policy renewals, to potentially explosive growth.
For health plans, challenges in the second year of the public insurance exchanges feature something old and something new.
Chris Johnston
Associate VP of New Business
and Consumer Solutions,
Health Alliance Plan
Last fall's nearly disastrous rollout of the federal government's exchange website, HealthCare.gov, has carriers casting a wary eye on the 2015 open enrollment period, which is slated to begin Nov. 15 and end Feb. 15.
Chris Johnston, associate VP of new business and consumer solutions at Detroit-based Health Alliance Plan, says that technology remains a top HIX concern on several fronts. The performance of the revamped HealthCare.gov website is a prime worry, he says: "How stable is it?"
Last fall, the Centers for Medicare & Medicaid Services scrambled to fix dozens of major flaws in the website. The agency brought in a new chief executive, Kevin Counihan and has been fine-tuning HealthCare.gov ever since.
On Friday, CMS released a mammoth amount of exchange data, including detailed information on insurance policy premiums. A preliminary analysis conducted by Washington, DC-based Avalere Health LLC found premium rates vary widely across the country but the average premium increase is modest compared to historical rate hikes in the individual market.
Avalere examined premiums for a key benchmark policy, the second-lowest priced silver plan, in the 34 states that use HealthCare.gov as their exchange portal. For those silver plans, the average premium increase for a 50-year-old nonsmoker is 3%.
CMS recently announced a "window-shopping tool" designed to help individuals review information about HIX insurance policies offered in their state before open enrollment begins. The tool enables consumers to compare plans, covered benefits, and physician and hospital networks.
Even if HealthCare.gov performs well for new enrollees, Johnston says CMS is facing a new technological challenge—policy renewals.
"We are on daily and weekly calls with CMS [along with] other plans across the country. They are new to this; we've been at this for years. They are learning. They're going to have to figure out how to renew people."
There are big issues for consumers who opted to authorize automatic renewals when they signed up last year, Johnston says. The problem is "they don't remember if they selected anything."
HAP is urging individuals who purchased 2014 health insurance policies to go back to HealthCare.gov and shop for new 2015 policies. Johnston says changes in income could affect subsidies available to individuals through the exchanges and there are new plans being offered in exchanges across the country, which "could be a better fit," Johnston says.
New York-based PricewaterhouseCoopers has been tracking 2015 HIX premium rates since the summer, featuring the consultancy's findings with an interactive map. Ceci Connolly, managing director at PwC's Health Research Institute, echoed Johnston's advice to consumers. "Simply auto-enrolling in your existing plan may not be the best choice in 2015. We are seeing wide variation in premiums, so it really pays to shop around," she said this week.
Enrollment is just one side of the HIX technology challenge, data is another. Health plans are still getting shaky information on beneficiaries from CMS, he says. "We need accurate information on who was enrolled in our plan. We're still having some problems."
Aetna is also highlighting "back-end" technology concerns.
"Certain functionality gaps still exist, adding to member confusion as they seek out other ways to make changes to their information. For example, members are using CMS Customer Service to request effective date changes that should be able to be processed through the website," the insurer said in an email exchange.
Consumer Education Efforts
This year, health plans are taking new approaches to educating consumers. "Last year, because it was the first year, we really didn't know what to expect," Johnston says, and HAP focused much of its consumer education efforts on Michigan's low-income population.
"This year, we're doing more with advertising," he says, citing newspaper, radio and television campaigns.
Minneapolis-based United Healthcare has launched its own online tools to help individuals navigate HIX enrollment, a company spokeswoman said this week. "Our tools, Health4Me and myHealthcare Cost Estimator, are available to help individuals navigate open enrollment and understand how to use their health insurance benefits to become and stay healthier, as well as how to save on their healthcare costs."
The industry's trade association, America's Health Insurance Plans, has circulated two infographics to help its members explain the enrollment process to consumers. One infographic is targeted at new enrollees and the other is designed to help individualsrenew their HIX health coverage.
Reading the 2015 Tea Leaves
Growth appears to be the key word in the 2015 HIX market.
"This will be a growth year, so for the exchanges and the plans and healthcare providers, the challenge in 2015 is serving many millions more newly insured," PwC's Connolly says. "Health insurers and clinicians need to get a deeper understanding of this new customer base, their health status, and how they interact with the healthcare system."
Health plans are banking on HIX growth, she says. "What is perhaps most notable in the second year is the growth in participation by health plans. We count 77 new carriers competing in 2015. At least four states have double the number of offerings from last year. This suggests that the industry sees real opportunity in the exchanges and is pursuing these new customers."
UnitedHealth says it has doubled its participation in the public exchanges from about a dozen exchanges last year.
Private health insurance exchanges also are poised for growth, Johnston says, noting that HAP is participating in several private exchanges such as iSelect and Michigan's Insurance Marketplace.
"This has really opened up a whole new market as far as the [private] exchanges go," he says, which generally target the group market. "You can feel the momentum starting to ramp up," he says. "New ones are calling us every day."
Most private exchanges feature a "defined contribution" model in which an employer caps the amount of money it gives workers to spend on health insurance premiums. Then workers get a choice of policies with a range of premiums. "It's one way you can control the healthcare 'spend,'" Johnston explains.
Aetna says private exchanges appear destined to outpace the public exchanges. "Public exchanges can play a vital role in increasing access for individual consumers; however, the sustained success of HealthCare.gov depends on a fully functioning website that can support consumers through the enrollment process and for ongoing changes that occur during the plan year."
"When that happens, we believe public exchanges can complement the existing competitive marketplace, including private exchanges, which we believe, over time, will serve a much broader portion of the population."
In a high-stakes gamble, the biggest health system in Massachusetts is trying to get bigger, but its merger plan is in the hands of a Superior Court judge.
I expected a showdown at the court hearing this week on Partners HealthCare's quest to acquire three more hospitals in eastern Massachusetts. Instead, I witnessed a clash of constitutional titans.
MA Attorney General Martha Coakley
in Suffolk County Superior Court Monday
On Monday, Judge Janet Sanders was scheduled to hear from lawyers representing Partners and the commonwealth's attorney general's office about why their settlement deal on the merger plan is in the public interest. The hearing was slated to last less than four hours. It took all day.
The Suffolk County Superior Court chamber in downtown Boston was packed to capacity. At least 50 people, including Attorney General Martha Coakley, sat on the pew-like wooden benches in the gallery. The jury box was filled with journalists. The lawyers representing the AG, Partners, and the hospitals slated for acquisition were seated at two tables in the center of the room.
One lawyer each was present for South Shore Hospital and Hallmark Health System, which owns two hospitals in the North Shore region of the commonwealth that Partners covets.
And an attorney for a coalition of hospitals and physician groups opposed to the settlement sat alone on a document-strewn bench across from the jury box.
The only empty seat was in the witness stand next to the judge.
'I Have to Look at the Harm Alleged'
The hearing started calmly. Sanders said she wanted answers to two primary questions: first, whether there is a basis to conclude that the settlement deal would remedy the harms alleged in the AG antitrust lawsuit that had prompted the pact and whether the settlement was enforceable.
"I have to look at the harm alleged in the complaint," Sanders said. The judge referenced passages in the AG's lawsuit, including a claim that Partners' acquisition of South Shore Hospital, Lawrence Memorial Hospital and Melrose-Wakefield Hospital would "substantially reduce competition" as well as a claim that health plans need competing providers to negotiate affordable prices for healthcare services.
The judge then quizzed the AG's legal team on her second question: why the settlement deal proposes "conduct" remedies such as price controls rather than "structural" remedies such as health system divestments to offset reduction in competition.
"A structural remedy would have required litigation," replied Assistant AG William Matlack, chief of the state agency's antitrust division. He said the AG had to weigh "the risk we would litigate and lose versus settlement."
Sanders and Matlack went back and forth on the advisability of conduct remedies in the settlement deal several times. "I'm apparently not supposed to inquire [about] your likelihood of winning [in litigation]," the judge said.
Matlack replied that the AG's office had exercised its "prosecutorial discretion" in crafting the settlement deal and advised Sanders that the court is only supposed to determine "whether the enforcement action is reasonable."
The seed of confrontation had been planted.
Antitrust Remedies Probed
Before Sanders suspended the hearing for lunch, she started digging into the specifics of the settlement deal.
Her questioning focused on price caps Partners had accepted over a period of six-and-a-half years as well the health system's concession on "component contracting." The latter provision of the settlement deal would allow payers to accept pricing arrangements that apply to the entire health system or to cut pricing deals with separate Partners bargaining units over a period of 10 years.
Matlack contended that the price caps and component contracting amount to significant counterweights to the anticompetitive impact of Partners' proposed mergers. "The combination of the price caps and the component contracting fundamentally changes the negotiation dynamic," he said.
Sanders pressed for explanations of how the price caps and component contracting would work in practice. In an exchange with Partners' lead attorney, Washington, DC-based Bruce Sokler, she asked, "Why is a price cap going to be effective here?"
"The answer is, this is an antitrust consent decree, and antitrust is about price," the attorney replied.
The judge asked the AG lawyers about the likely market outcome after the price caps were lifted. "Once the time cap expires, Partners is unfettered. They are free to do whatever they want to do," Sanders said. "It is more likely there is going to be less competition in six-and-a-half years."
Matlack revisited the specter of litigation. "The comparison is what happens if we litigate and lose. We have nothing," he told the judge, adding that no one could predict the composition of the market years into the future. "It's not a foregone conclusion [that] there will be less competition in six-and-a-half years."
The questioning reached a fevered pace. As the lunch hour approached, Sokler attempted to draw a bottom line on the settlement deal. "What happened was, there was a negotiation and a compromise," he told Sanders, "and this is what has come out. Others don't like that."
Sokler said the AG's office had the authority to cut the deal. "That's why we negotiated with them," he said.
Then the confrontation sprouted.
Coakley rose from the gallery and asked for permission to address the court, which Sanders granted.
"We have come to this really over the last eight years," the AG said, gripping either side of a small wooden podium in front of the gallery. "We set up a healthcare department in the office. We have been the only agency in this state to shine light on healthcare disparity."
Coakley made a spirited defense of the settlement deal. "We worked very hard, very diligently at it. This is about what is in the best interest of leveling the playing field given where it stands now," she told the judge. "I believe the work has been done. I believe you have the information before you to make a decision."
Sanders decided it was a good time to break for lunch.
Clash of the Titans
Although fatigue was setting in, the afternoon session had a high-stakes edge.
After finishing her probe of price caps and component contracting, Sanders turned to questions about whether the settlement was enforceable. "I think it is admittedly very complicated," she said.
As the light pouring through the courtroom windows started to fade, the judge began a line of questioning she probably regrets. Referring to the results of last week's election, she said "We do have a new attorney general [set to take office in January]. Should that new attorney general have an opportunity to look at this?" she asked the AG legal team.
Coakley, who ran an unsuccessful gubernatorial campaign, will be handing over the AG's office to fellow Democrat Maura Healey.
First Assistant AG Chris Barry-Smith all but accused Sanders of usurping the executive branch's authority. "It's critical that there not be a precedent… that work cannot continue and work cannot be finished," he told the judge.
"There's a political dynamic," Sanders insisted. "Surely, we should make sure the incoming attorney general is behind this."
Barry-Smith stood his ground. "It's the institution that is the steward of the public interest," he said.
Coakley was soon on her feet again. "I want to be clear that the decision we made had nothing to do… with the office I was running for," she said.
Sanders replied that she had not meant in any way to "impugn the integrity" of the AG.
"I think you have," Coakley quickly shot back.
After a rhetorical dance that mirrored two gladiators circling one another in a coliseum, the judge returned to an apologetic tone. "The courts try to function in a political vacuum, but there are real life things that happen," Sanders said. "I am not in any way trying to impugn your integrity."
The judge adjourned the hearing moments later. Based on comments Sanders made during the proceeding, she is not likely to issue a ruling on the settlement deal until December at the earliest.
As Coakley and her legal team headed for the lobby, I asked her whether she had planned on addressing the court. "I felt that at the end… it was important for [Sanders] to hear from me," she replied.
The Bay State is leading the country in establishing price transparency for healthcare services, but setting quality standards and wariness among providers are significant obstacles.
A recently adopted state law has moved Massachusetts to the front of the national class on price transparency.
Suzanne Delbanco
The price transparency provision of the 2012 law, Chapter 224, went into force last month making Massachusetts one of the first states to require healthcare providers and payers to make medical service prices accessible to the public.
In March, The Bay State and Maine earned the highest national grades for price transparency from Berkeley, CA-based Catalyst for Payment Reform. Forty-five states received failing grades.
"CPR believes price transparency is a fundamental building block of a higher-value healthcare system," says Suzanne Delbanco, the organization's executive director. "We will be evaluating any new laws to produce an updated 2015 Report Card. My sense is these two states likely continue to lead the nation, along with a small number of others like New Hampshire and Colorado."
Barbara Anthony, Massachusetts undersecretary of consumer affairs and business regulation, says her agency has high hopes for the impact Chapter 224 will have on healthcare in the commonwealth. "This is going to drive down costs over time at providers," she said. "This is how markets work."
Anthony says states are facing several challenges establishing healthcare price transparency, such as building websites that are capable of providing consumer-friendly access to medical service price information. The biggest challenge is changing mindsets, she said.
"This is more than just a website, this is an effort to change attitudes," she says. "We wouldn't think about buying a car, a television, or any sophisticated piece of equipment without doing our homework… You have to feel comfortable taking charge, which is a challenge."
The mindset hurdle extends beyond consumers to a key healthcare stakeholder, Anthony says. "We don't hear resistance from insurers. Where we hear resistance is from some provider groups. Not everybody is at the same level yet. This is a collaborative situation. When the insurers and providers are willing to have a discussion about value, [pricing] is not going to be a secret discussion anymore."
Provider and Payer Perspectives Differ
Chapter 224 requires both providers and payers to make pricing information available to the public, but they apparently have varying enthusiasm for the new law.
"Our industry [and its members] have been strong advocates for price transparency," said Eric Linzer, senior VP of public affairs and operations for the Massachusetts Association of Health Plans. "It allows consumers to shop and compare prices across different service types… These are tools to encourage individuals and employers to really engage. Without that information, it makes it really hard for health plans to expect people to make informed choices about where they get their care."
Massachusetts health plans have launched pricing websites crafted to individual beneficiaries such as EmpowerMe at Watertown, MA-based Tufts Health Plan and SmartShopper at Worcester, MA-based Fallon Health.
"In partnership with Compass Healthcare Advisers, the Fallon SmartShopper program provides real-time cost transparency for all Fallon commercial plan members and incentive rewards for many commercial group members," says David Przesiek, VP and chief sales officer for Fallon Health.
"We believe that [the tool] is a way to reward members for taking a proactive approach to their own healthcare. Not only will the tool educate and empower members to choose the care that is right for them, but it will help members to save money on procedures while earning incentives."
Karen Granoff, senior director of managed care at the Massachusetts Hospital Association, has a more cautious perception of the commonwealth's price transparency push.
"The Massachusetts Hospital Association is in favor of price transparency, but it's important to keep in mind that price is just one factor to consider in deciding where to receive care. Other considerations include quality, the ability to share information via electronic medical records, and whether a particular facility promotes patient-centered medical homes; for example, by allowing primary care physicians to help determine where care can be provided so it can be integrated effectively with all of the providers caring for a patient," she says.
Price transparency is a laudable goal, but it has the potential to undermine other healthcare initiatives, Granoff says. "On the one hand, the state is promoting integrated care, including accountable care organizations and patient-centered medical homes, while at the same time encouraging patients to shop for the best price. This 'shopping' paradigm may not always be consistent with promotion of care integration."
Quality Data Poses Challenge
In economic terms, the value of a service can be boiled down to a consumer's assessment of cost and quality. While there is widespread agreement in Massachusetts that Chapter 224 has made a giant leap forward in publicizing healthcare service costs, there is an equally broad consensus that greater strides must be made on the quality side of the healthcare value equation.
Anthony says most Bay State health plans include "some kind of quality metrics for providers" on their websites, but she acknowledges that more work needs to be done. "This is an area that needs attention. This is an area where we are lagging a little bit," the undersecretary said.
Linzer says an arduous effort will be required to reach the point where Bay State consumers can make fully informed decisions about healthcare value. "These tools are in their initial stages. These websites will mature. These websites require a significant amount of work and significant information technology build."
Granoff says making healthcare service quality data easily accessible to Massachusetts consumers is a work in progress.
"Payers and providers are trying to incorporate quality information with the pricing information that's provided, and hospitals and insurers alike agree this is critical. However, there are not always good metrics available for all types of procedures or for comparing physicians, and different payers may use different metrics, so it's not always comparable. It is evolving."
Delbanco says the quality factor in defining healthcare service value remains a daunting hurdle. "Most health plan tools these days do incorporate some quality information, but not in a way that is very useable by most consumers."