Massachusetts is the first state to say that health care costs must stop increasing faster than that of most other goods and services.聽Prof. Stuart Altman,听听飞丑辞听advised President聽Richard聽Nixon on health policy and ,听has responsibility for helping the state achieve that goal.聽聽
Gov. Deval聽Patrick聽recently named Altman to chair the Health Policy Commission, the new board overseeing the sweeping cost-control law. The board, whose other members were ,听will monitor progress toward keeping health care spending in line with state economic growth overall. While he鈥檚 鈥渉opeful鈥� the state can meet this goal, Altman notes that many attempts have failed over the years. WBUR鈥檚 Martha Bebinger spoke with Altman聽about the challenge. Here is an edited transcript of that interview:
How do you see this new role?
Massachusetts has put together the best kind of balanced program that I could think of in the country, where it is relying at one level on the many changes that are going on in the private sector.聽But it also has put together an overarching public assessment of what鈥檚 going on to make sure that it works, and it actually brings cost down without hurting quality.
Stuart Altman (Photo by Bill Greene/The Boston Globe via Getty Images)
If the changes that are currently in place don鈥檛 do that, this commission is responsible for giving an early warning sign.聽So we don鈥檛 have direct regulatory power to force the system to change, but we do have a monitoring role to make sure that it is working. If it鈥檚 not, [we would] first direct the delivery system and the payers to change, and if that doesn鈥檛 work, we could also recommend back to the legislature that the state needs more authority.
What is your sense going in about whether things will proceed without too much intervention, or whether you will need to be directive?
On one level I鈥檓 pretty optimistic.聽The level of changes that are occurring in the state are really very substantial.聽And I would say that the delivery systems,听including our very big delivery systems, they really are seriously trying to restructure聽to live within a tighter budget than they had in the past.聽And the payers too 鈥斅燘lue Cross,听Tufts and Harvard also 鈥斅燼re tightening up the reins and not giving big increases.
But I鈥檝e been around a long time and I鈥檝e seen other years and other decades when after a while the cost-containment mechanisms in place began to fall apart, and did fall apart.聽So while I鈥檓 going into this quite optimistic, I also have a degree of skepticism so I鈥檓 going to be watching it pretty closely.
You have seen interest in reining in costs wax and wane. How do you rank this period?
If we look back in history we had very strong government regulation environment in the early and middle 1970s, actually put forward by a Republican administration. It looked like the government was going to be a very strong regulator of growing health care spending.聽 We had wage and price controls from 鈥�71 to 鈥�74.聽 We created health planning agencies all over the country. We had tough certificate-of-need laws.
And then as we move through the 鈥�70s we gradually dismantled it all and by the end of the 鈥�70s, it was all gone. Then we had a very brief period when the providers had what we called a 鈥渧oluntary effort鈥� to control their spending.聽All that fell apart and we had the biggest growth in our history in the 1980s.聽
Then we introduced managed care, which was extremely effective in slowing the growth in spending, but it was perceived by the patients 鈥� and the beneficiaries and the press 鈥� as a system that was holding back access and quality. We had this strong backlash and we essentially destroyed managed care by the end of the 鈥�90s. So I鈥檝e seen both the private sector fall apart and the government sector fall apart.
Now, I think what鈥檚 being done is smarter, and not quite as aggressive as the 鈥�90s, which I think is a good thing. If you鈥檙e too aggressive you鈥檙e going to get a lot of backlash too quickly.聽So I give it a higher probability of success than either the 鈥�90s or the 鈥�70s, and I am hopeful.
What鈥檚 your main worry?
There are two:聽
Ultimately the constraints begin to hurt certain segments of the provider community, [and they] begin to put out statements to the patients that they鈥檙e being denied needed care and we begin to develop a new backlash. So I think patients need to be part of this equation and we need to be balancing their needs with the people that pay the bills, so that鈥檚 one side.
Massachusetts can only be so far ahead of the rest of the country. If inflation really begins to rear its head again in the rest of the country, the likelihood that Massachusetts would be able to really have a significantly lower level of spending growth is hard to hold on to.聽I鈥檓 going to be very conscious of trying to minimize any backlash and I鈥檒l also be watching what鈥檚 going on in the rest of the country.
For patients, are things moving along now in terms of communicating clearly with patients as you think they should?
No. I don鈥檛 think patients really understand these limited networks and tiered networks and ACOs and the like.聽I think there needs to be an expanded consumer education program.聽Also I think we need to do it smarter.聽You don鈥檛 force a patient into any one delivery system, you just make it more expensive if they jump out of one to the other, which continues to gives them the choice.聽What happened in the 鈥�90s is that often they had no choice, they had to be at a particular network and they couldn鈥檛 jump out.
So I think we鈥檝e learned something in the last 20 years.聽If we鈥檙e going to ask organizations to have responsibility for total spending of a particular patient population, [the patients] need to know they鈥檙e in a particular group, but they also need to have the flexibility if for some reason they want to get out. I think we need to better educate our consumers and patients, but I think we鈥檝e also learned from the 鈥�90s, so I鈥檓 hopeful.
This story is part of a reporting partnership that includes ,听 and Kaiser Health News.