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Meanwhile, back here in Boston

Posted Aug 17 2009 10:12pm
Let's shift attention briefly from from the national arena discussed below to the local scene.

I am always inspired when I read articles by Don Berwick and Atul Gawande. In addition to substantive wisdom, they have a fluid and persuasive style. Such is the case in an August 12 op-ed authored by the two of them and Elliott Fisher and Mark McClellen in the New York Times. They rightfully point out that, if medical systems across the country adopted reasonable steps in the use of evidence-based medicine, quality and safety, collaboration and efficiency, the current national debate about how to afford universal coverage would disappear.

This is not a new message for these authors, but there is little evidence to date that it has been internalized by doctors and administrators throughout the country, especially here in Boston. To put it in medical terms, we know what medication needs to be taken, but the patient is not being compliant with the prescription.

My friends at Blue Cross Blue Shield of MA believe that a change in the payment system, from fee-for-service payments to a capitated system, is a primary way to help solve this problem, and they are supported in this view by the recently convened Payment Reform Commission. They may be correct that it would be helpful, but only if there is sufficient state regulation of rates to counterbalance the market power of the state's dominant health care system and to get its disproportionate reimbursement rates under control.

But I think the advocates for capitation would be among the first to admit that the other opportunities mentioned by Berwick et al are not dependent on changes in reimbursement rates. In fact, the op-ed makes that point, noting that lower-than-average costs have been achieved even in some communities that do not have a capitated form of reimbursement.

Here in Boston, competition among hospitals has driven costs up, not down. The hospitals' drive for market share combined with doctors' desire for the latest prestigious machine, lab, or building leads to a medical arms race in this city. Efforts at collaboration or rationalization of services among the academic medical centers -- even those in the same system -- routinely fail. Closure or consolidation of ailing hospitals is very difficult and unusual, in that financial rescue is often offered by a state Legislature concerned with constituency issues. And, as noted above, contrary to other parts of the country where there is a dominant provider concerned with lowering costs, the one in Massachusetts has used its market power to raise costs in a manner that has not been effectively challenged by the insurers or their subscribers.

So, for the next article, I'd like to see these authors or someone else address the on-the-ground problems of the Boston metropolitan service area. Is it possible to take the broad themes from the op-ed and bring them back home and advise this group of patients how to take their medicine? Or is there something about this organism that suggests a different diagnosis and treatment plan?
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