The House version of payment reform creates a new mega agency, the Division of Health Care Cost and Quality. To be fair, the House collapses a few other state agencies into the new Division, but there is no question this entity is given far-reaching and broad regulatory power. The Division will be independent and “not subject to the supervision and control of any other” public entity. (Section 29, subsection 2(a))
The controversial federal Affordable Care Act drew negative attention for how many times the Secretary of HHS was instructed to act on major policy, roughly 700 times in 2,700 pages.
The House’s bill outdoes the ACA by requiring the division to take action 163 times in 178 pages, or almost once every page. The mandate approach results in 941 instances in which the House mandates action in the bill, by using the word “shall.”
A sample of the dizzying and expansive Division’s responsibilities includes but is not limited to:
- Assessing a number of penalties, fines, and surcharges. I counted 26 in the bill. Some are one-offs, others reoccurring and some are sticks to be utilized to guarantee compliance. Of course, most of the cost of these will be passed onto patients one way or another.
- Setting acceptable standards for alternative payment methodologies.
- Overseeing and being involved with alternative payment contracts.
- Developing quality metrics including parameters for clinical outcomes, but limiting insurer’s use of quality data outside of division approved metrics.
- Defining and overseeing accountable care organizations on many levels.
- Designing and managing the state-wide health technology infrastructure needed to meet the mandated 5-year window for Health IT.
- Monitoring and participating in workforce development and planning. Including multiple student loan forgiveness programs, and other recruitment and retaining programs to keep doctors in state or practicing in under-served areas.
- Setting out extensive mandated transparency mechanisms for consumer education on cost and quality data and trying to improve administrative simplification.
- Surveying patients annually for their perception of access to services, including many subgroups such as the homeless.
Yet many questions about implementation remain, and policymakers should look very closely at the following:
- Will transparency without the correct tools and incentives for consumers backfire? For many patients, high-cost correlates with higher quality. Of course the Attorney General’s report proved this theory wrong, but if you provide patients with cost data but their health plan is not set up to incentivize the use of low-cost high-quality providers, you will have many seeking out the most expensive folks. (The direct opposite goal of this legislation.)
- As the Division sets up uniform reporting of revenues, charges, costs, and utilization (that by statute will need to be in line with federal reporting standards) will the state follow the federal government’s ACA lead of 140,000 coding categories? For example, if you’ve been bitten by a turtle for the second time you would use code W5921XD.
- Will the Division have the expertise and technological knowledge to implement the many goals laid out in the legislation? Even with numerous expert advisory committees, many of the functions the Division will be conducting are replicating what the private sector currently does. One only has to look at the Health Care Cost and Quality Council to see an example of a great public advisory board that has struggled to produce a meaningful product that has wide market penetration. Policymakers should ask if is a good investment to ask a public entity to run so much, when you are trying to reduce spending.
- The issue of privacy and health information technology is complex and expensive. The bill currently waves its hand on this issue, and serious thought is required.
- What will the Division cost to run? The most likely smaller Connector costs roughly $30 million a year to run. How much more should we expect this mega-agency to cost?
- Finally, policymakers should take a serious look at the wide-ranging authority given to the Division. On multiple occasions, the Division is instructed to “take actions necessary to ensure….” or “promulgate regulations or guidelines to implement the findings of this section.” We must ask if we are comfortable with bureaucrats holding the reins to 18% of our state’s economy, that may not have the expertise, resources, or shared values that we do to balance the trade offs associated with government centered cost controls. They decide where billions of dollars will be directed or granted from trust funds. Do we trust their judgment and are we confident that industry influence will not sway these few government officials?
Much more to come.
Find me on twitter: @josharchambault
I love this bit, from the second paragraph:
“Negative attention” from whom? For that matter, “controversial” according to whom? The lunatic teabagger fringe that regrettably has taken over the national Republican party? Or someone with something intelligent to say?
Good Lord, do you have any basis for such an outlandish assertion? I’d sure like to see it. It’s fascinating to me that, on the one hand, Pioneer seems strenuously opposed to any sort of government regulation of anything, yet on the other, doesn’t trust individuals to make intelligent decisions without being “incentivized” (there’s a truly creepy word) to do what Pioneer thinks they should do.
This, of course, is Pioneer’s bottom line:
Yeah, ’cause gosh, the “free market” has done such an awesome job so far in controlling health care costs. Get the gubmint out – that’ll solve all our problems.
This kind of petty, dog-whistle post that says nothing at all constructive is, frankly, disappointing from an institute that tries to present itself as a serious participant in important public policy discussions.
Oooh, I can’t wait.
This can be seen from their utter failure to grapple with the fundamental problem of the US health care system: it provides second-rate care that is more than twice as expensive as any other comparable country’s, all of which are organized around a system of public control. By their logic, the biggest problem with this country is that we aren’t more like Somalia, where there is no effective government. You’re right, though: their posts show the emptiness of current GOP/libertarian ideology. They don’t have any credible alternative to offer other than: we trust Pfizer et al to do what’s best for the general public, even though they have no legal obligation to do so, and will not be rewarded for it.
This is why people think rhetoric means bullshit. Rather than a substantive, evidence-based persuasive argument, Pioneer has spun out a well-worded load of misleading crap.
Notice that he cuts the quote short before finishing the sentence, which reads:
So what the quote in context is actually saying is that no public entity OTHER THAN that which is written into the law as having authority over the division, can arbitrarily control the operations of the division. It is limiting the power of government, though Pioneer took it out of context to make it sound like the division’s power is unlimited. Typical tea party sleaziness.
Not to mention, that language is nothing new or unprecedented. Plug that phrase into google and you’ll find a list of laws that include the exact text… including Chapter 176Q for the establishment of the Commonwealth Health Insurance Connector. moving on…
What is law other than language for government action? Laws determine all that the government shall provide, tax, prohibit, and protect. Pioneer is making the status quo sound radical.