You might think that if you pay the premium for the fancy downtown hospitals (under Partners HealthCare) that you'd be getting the tip-top quality you and your insurer are paying for. You'd be wrong about that. Finally, in a major report out today, the Globe got its paws on some of the hospital quality data that the hospitals have been keeping all to themselves.
Call it the best-kept secret in Massachusetts medicine: Health insurance companies pay a handful of hospitals far more for the same work even when there is no evidence that the higher-priced care produces healthier patients. In fact, sometimes the opposite is true: Massachusetts General Hospital, for example, earns 15 percent more than Beth Israel Deaconess Medical Center for treating heart-failure patients even though government figures show that Beth Israel has for years reported lower patient death rates.
Private insurance data obtained by the Globe's Spotlight Team show that the Brigham, Mass. General, Children's Hospital, and a few others are, on average, paid about 15 percent to 60 percent more than their rivals by insurance companies such as Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care. The gap is even more striking for many individual procedures, which can be two or three times more expensive in one hospital than in another.
It should drive everyone absolutely nuts that a.) there are confidentiality agreements regarding payment; and b.) that the hospitals don't willingly disclose their own quality data as a sign of good faith.
I remember over a year ago hearing MGH CEO Gregg Meyer explain away the hospital's resistance to publicizing a particular quality indicator (HSMR) by saying essentially that the public might misinterpret such data.
I'm more irritated about that now than I was a year ago. That is an utterly bogus excuse — completely self-serving, and manifestly to the detriment to quality care, our wallets, and indeed to his hospital's reputation. Health care is indeed a marketplace. A marketplace without information is not a market at all — it's a shakedown.
And they're still trying to keep the rest of the quality data under wraps — in contradiction to the express intent of the Chapter 58 legislation:
The law calls for the council to post insurance claim information on the web so that the public can see the disparities. But a year and a half after the law was passed, the council has still not published its findings because of disputes with medical groups about how the numbers should be presented and whether they are accurate in every detail.
Outrageous. They don't want to have to earn their sterling reputations — they just want us to pay through the nose for it.
The game is up; the reputations are sullied; everything is suspect. We already knew this was true, after all. If the hospitals don't come clean themselves — now — the legislature should be prepared to:
- Outlaw confidentiality agreements regarding cost of services.
- Publish the quality data currently under wraps, pronto.
- Strongly consider smashing the cartel of Partners: MGH + BWH.
If we indeed have the best health care in the country right here in MA, it's time for the providers to earn that status. Free the data!
As an actuary about the tone of the article. First thing I noticed was this:
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p>But how in fact do you quantify this? And how do you actually interpret the data in a rational way, given that far more serious cases seek out a MGH or a Brigham Womens’? Not sure that I actually trust a bunch of newspaper reporters to interpret raw data in a sophisticated way other than to generate a headline.
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p>Too much personal experience in the past with the gods at MGH to question them; all well and good to save a buck if you can, but how do you quantify life or death when choosing a hospital for a serious treatment? My wife (thyroid cancer), a neighbor (brain aneurysm), and now hopefully my brother-in-law (liver cancer) owe their lives to being treated by the best in the world. As my friend said 2 months ago, he felt a little guilty going in for his radiation treatment for a brain aneurysm after talking with everyone else waiting for the same treatment. He was the only one who could drive to MGH; everyone else was from all over the country.
Who is presenting to MGH and in what stage of cardiac disease? How do the demographics of the patient skew survivability and outcomes? “Heart failure” means a lot of different things. Some people walk around in cardiac failure for days; some people die of sudden cardiac death in minutes.
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p>The Globe statement is lazy and ambiguous. If they’re going to step into the clinical arena touting facts and figures, they need to be more careful and specific in arriving at their conclusions.
… has created a single statistic, Hospital Standardized Mortality Rate, that is supposed to correct for all of the factors you describe. I am not a statistical expert, but this group seems to be very well-esteemed.
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p>The point is that MGH/Partners could release all that data. They could be transparent, they could be clean, but they actively decide not to, because they don’t trust the public with that data. Why not? Well gosh, it might not be flattering to their top-flight reputation!
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p>So if you don’t trust Globe reporters’ judgment or description of the data, that’s all well and good. Skepticism is always warranted. But the hospitals are making it damn near impossible to have an open, good faith discussion about quality and price. And it’s because they’re making good money doin’ what they’re doin’.
Except that there are stringent federal laws (HIPAA, and others) regarding patient privacy, so there’s plenty of data they couldn’t release.
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p>I’m with the previous commenters – if one hospital takes all the dangerous, risky, complicated operations, and another one doesn’t, there will be a difference in costs and survivability rates.
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p>Statistical corrections work on macro levels – if done right – but they don’t do well with micro-variations, which is exactly what healthcare is.
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p>Heart operations are dissimilar – shopping for one isn’t like comparing a car across different dealerships.
If you remove anything that can identify the patient, like address, SSN, etc. information can be released. It is common that they remove this information in case mix reporting.
I hope the Globe’s investigation is just the beginning of a series on how Partners/MGH has driven up the cost (but not the quality) of care…and how Partners predatory plans and actions to expand into the suburbs are actually diminishing our choices by making it harder for community hospitals to survive.
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I’m reprising my comment at the Globe story page:
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p>It’s important to point out that patients do not have control over insurance reimbursement rates, and so to conflate the terms patients and consumers is to perpetrate an injustice.
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p>Moreover, the terms treatment and care are conflated, and they are not the same. In general, physicians treat, while professional nurses care. Not once was the word, nurse, used in the story. But it’s the absence of professional nursing that is at the root of much of the problem.
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p>Nurses provide over 95% of all reimbursed healthcare services (The Commonwealth Fund), although their costs are most often hidden in the room and board general charges, which is unacceptable. In current practice, nurses work as employees, and they are torn by loyalty to employers, which can withdraw their means of livelihood for advocating for patients and nurses, and often do.
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p>Nurses and physicians have many similar aims, and they should consider looking for opportunities to collaborate such as in a model of self-governed professional practice groups, where they select their own members and leaders, contract directly with groups of patients, businesses or patient care institutions to provide negotiated professional services, and thus, can advocate much more effectively for reasonable patient case loads, for safe and reasonable practice conditions and for patient safety. This model has several advantages: it provides a larger united collective representation model for the key providers of professional healthcare services, the numbers of nurses and physicians together creates a synergistic effect to return practice autonomy and authority for the respective members of those two professions instead of allowing it to be usurped by administrators, insurers and other commercial entities, and it provides for the selected leaders to be accountable to the professional membership and patients instead of exhibiting loyalty to employers and third parties, thereby strengthening collegiality and trust.
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p>The public is not at all informed about the vital and legitimate role that professional nurses provide – especially so in Boston after the nursing leadership pioneer, Joyce Clifford, was chased out of her critical nursing leadership role at Beth Israel when it partnered with the Deaconess. But it’s the presence of absence of nursing care provided by nurses with at least baccalaureate education that makes significant differences in whether patients experience preventable complications, preventable suffering and preventable deaths.
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p>I blog ad nauseum about these types of issues as well as health policy, professional nursing and patient advocacy, so will not hijack here.
for this statement:
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p>My gut reaction is that this statement is absurd, so I’d like to read the actual detail on this for my own edification. Thanks.
Mea culpa – I’m not finding the stat from the Comm. Fund – I have the cite buried somewhere on my blog and will keep looking, but in the meantime I found a similar source for it:
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p>American Hospital Association. Hospital Nurse Recruitment and Retention, A Source Book for Executive Management: Chicago, AHA, 1980.
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p>I think the large percentage arises from the type of round the clock nursing that inpatients receive in hospitals, hospices, nursing home and assisted living facilities, as well as for some intensive home care cases (most likely involving ventilator dependence and IV therapy).
The source you link above says this:
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p>This makes perfect sense since we are talking about direct care in a acute care setting. That, however, is a far cry from “[n]urses provid[ing] over 95% of all reimbursed healthcare services.” The former is about direct clinical patient care while the latter is about (directly) reimbursed services–not the same thing at all.
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p>I appreciate your efforts in trying to nail this down. It’s too important a point to leave unsubstantiated.
we’re going to blow the HMOs out of the water…
So they are making two points:
– Partners is big and has nice hospitals, people want to be treated there, so Partners can extract more from the insurance companies.
– The quality of care is not necessarily linked to the pay, so Partners and other Boston hospitals are overpaid.
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p>The second point may or may not be valid. A solution to it will be publishing better comparison data in a format that a layperson could understand. Then, an insurance company could suggest folks to go to a local hospital instead of MGH, citing the numbers proving better quality of care.
But I don’t get the first point at all. People want to be treated at Partners’ hospitals, so Partners can demand more money. In my eyes, this is the same as iPhones costing more than your run-of-the-mill Nokias. Both provide about the same call quality, yet there’s a lot of folks who prefer iPhones so they cost more. What’s the big deal?
You don’t pay by 3rd party for an iPhone. This is where things breakdown when you talk about the cost of health care.
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p>You don’t go to a hospital and pay when you leave, you provide an insurance card for coverage, so you can go to Mass General or South Shore Hospital etc. and it doesn’t matter you pay the same amount in co-pay, coverage etc.
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p>What Charley discusses here is a major problem with the health care industry, it’s all done without any public knowledge is behind the scenes. No one is provided any details, we need to shed some light on to the process.
particularly for opening performance data with meaningful interpretation (for example, the mortality rates at MGH that are same or higher than at other hospitals could be a sign of not-so-good quality of care, as the article implies; or a sign that they get harder cases to begin with, as some commenters to the article said).
But if, given the same co-pay, patients prefer MGH to a local hospital, I don’t see why MGH should not request higher compensation from the insurance providers.
… have also pointed to a non-correlation between expenditure and outcome.
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p>The idea here is that Ezra thinks that making medicine more data driven is a potential place to make dollar efficiency gains. It has been noted that the VA has done well in “electronic health records” and it makes me wonder if the data in the details of the VHA prize (mentioned below) showed a better correlation of expenditure to outcome than other examples:
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p>Presumably, whatever Parters’ reputation is, it seems that they are still vulnerable to the phenomenon illustrated in the Medicare plot above, perhaps for the reasons Ezra indicates as well. OTOH, they could, with their extra cash, make investments to become more data driven. I don’t know if their efforts alone could generate efficiencies, but either way it might be a way to save face.
Nor do I think we should do so. I do think that we should have that information publicly available but not for payment. Similar to Medicare we should pay a “fairly” set cost for a procedure, there are other factors like costs in rural area and cities, etc. that should be factored in (which Medicare does) but have a set payment. These are similar to the APC and DRG rules already setup.
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p>One thing that is starting now and will be required for reporting purposes for reimbursement is “Hospital Acquired Conditions” (HAC), that’s a nice way of saying that the hospital in one way or another screwed up, be it an infection or operation on the wrong leg, etc. Currently, hospitals are paid to treating HACs, this will no longer be the case. Reimbursement will only be made for your original diagnosis. This is a small step in the right direction.
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p>This goes back to Universal Health Care, but Medicare for all of the Republican stammering works very well. Defining set rates, which including addons for other cost factors is what need need across the board. No backroom deals on payments. This is the only way we can keep costs low, I don’t see any other way around it.
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p>Plus, for the VA and EMR. I’ve been involved in EMR projects for a while now and it just gives me a headache. I would say that Obama needs to do something in defining a set format and a means of centralizing data, it could be regional as some groups are doing now. But what is needed is leadership on the issue. The VA’s project is a good starting point.
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p>Regional RHIOs by themselves is not the answer. There needs to be a top / down solution, not different groups doing different things. There has been a lot of good work done in the area but Dubya hasn’t done much in his second term. The project needs money and leadership.
I think I get where you are coming from, but I think you overstate the position. (The question of ‘measurement’ and ‘outcome’ is a frequent topic among education policy wonks as well and sparks debates about efficacy of standardized tests. ) Certainly if outcome isn’t really ‘matchable’ then of course it would be a waste of time and resources to attempt to match them. But if it is indeed true that some given specific types of expenditures in some given specific situations do not lead to better outcomes,… call me crazy but that seems like useful information to know in any system, including one where costs per procedure are ‘fairly’ set. The broad measure of dollars to outcome can be an indicator of where more data is needed to find out what specific expenditures seem not to result in better outcomes. I certainly can’t envision a world where outcome is divorced from consideration of costs.
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p>I’m not 100% in the ‘delivery system reform’ camp, nor 100% in the ‘financial reform camp’. I’m probably more in the latter than the former though because I’m betting that the cost efficiencies to be gained in the latter probably dwarf the former. But if real data can point to delivery system efficiency gains, I don’t the we can ignore it and continue to claim to be reality-based.
My years of work as a nurse in just about every different healthcare setting (MGH in-patient oncology, hospice, home care, community health centers) informs me that we should stick to basic common sense and approach the reform of health care as system reform (dysfunctional as it is, it does function as a system with inseparable parts; as John McDonough, Ted Kennedy’s new health care staffer explains these interrealted components: 1) Coverage, 2) Delivery, 3) Public Health, 4) Financing). And, as always, it’s useful to overlay this common sense approach with a healthy dose of “Follow the money trail and evaluate who wins and who loses” under the various “reform” plans proposed to help you understand the battles that will surely unfold as reform efforts move forward.
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p>Keep in mind that every other industrialized country has some form of national health insurance that GUARANTEES care to all without using the absurd layer upon layer of corporate insurance middlemen that the U.S. system suffers from. (Key point: a system that guarantees care to all using a financing mechanism where everyone pays in their fair share is NOT THE SAME AS A MANDATE TO BUY INSURANCE).
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p>Does anyone else interpret the Globe Partners gotcha article as, in part, a thinly veiled attack by MA BCBS on Partners? Follow the money tail works here, too: Did anyone else notice–and get seriously irritated by the fact–that for days and days leading up to the Nov 4 election the Globe OpEd page Partners HealthCare featured $10K infommercials about how great they are, while at the same time the major major MA news websites (Globe, NECN, etc…) featured very prominent, read “expensive”, ads by BCBS MA? Whose health do these ads help??? And did you see yesterdays Globe infommercial from Partners in response to the Sunday article??!!
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p>What these observations lead me to say is “Don’t let these profit-driven corporate entities distract us from the real discussion that must take place!” What we really should be discussing is this: Do we Americans want to continue a commercial and profit-driven system for health care (that has us paying twice as much and has receiving much less), or do we want, at long last, to join the rest of the civilized and industrialized world and create a national social insurance program that will GUARANTEE care for all? Yes, it will be a fight, but most very good things are worth the fight.
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p>The varied national health insurance programs around the world have core elements in common that include being financed by taxes from individuals and employers and all SPEND ABOUT HALF AS MUCH per person as the U.S. and all get better health outcomes with their much lower spending. Hhmmm…follow the money trail…who wins and who loses under these various approaches?
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p>Physicians for a National Health Program at http://www.PNHP.org is indeed a great resource. It’s part of the growing coalition supporting HR 676 (“Expanded and Improved Medicare for All Act/ The United States National Health Insurance Act”), as is the National Nurses Organizing Committee at http://www.guaranteedhealthcar… and Progressive Democrats of America http://www.pdamerica.org/artic… along with over 400 LABOR organizations across America that have endorsed HR 676!!!
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p>Instead of expending our energies getting drawn into the Partners/MA BCBS “market share” battles, I urge you to think about joining up with HealthCare-Now, HealthCareForAmerica-Now, Campaign for America’s Future, USAction, MoveOn, ACORN, SEIU, Ted Kennedy, Al Gore and so many other strong groups and individuals who are now publicly committed to the fight for a humane and civilized national health program. Make no mistake, this is a huge huge battle we are waging. Please use the above links to educate yourself and then your neighbors and co-workers about creating the choice for Improved-Medicare-For-All NOW!
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p>Thanks.