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Can you afford a medical visit?

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    Can you afford a medical visit?

    You're not going to get a useful understanding of the competing health-care cost-control measures from the Boston Globe. It has--to start with--no reporter even able to read and understand the bills proposed by the Governor, state Senate and House. Liz Kowalczyk, who writes most of the Globe stories on these topics, is challenged by fourth-grade arithmetic and totally dispossessed by strong personalities.

    One useful outlook comes from Paul Levy, former head of the Massachusetts Water Resource Authority and of Beth Israel Hospital--for neither of which his background equipped him. [ Vying bills in the legislature, May 9, 2012, at ]

    Mr. Levy sees the fracus as typical state politics, with the usual bludgeons from Blue Cross and the other "big money" insurers. He says, "The insurer [Blue Cross] offers an unproven hope that a change in rate design [so-called 'accountable care' groups] will undo its actions."

    If you think that the situation is somehow rational, you may be in need of a refresher about the Curley administrations in Boston and the Furcolo administration of the state. which the current situation with health-care payments closely resembles.

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    Primary care

    Chelsea Conaboy, who may not understand so-called "health-care cost control" bills in the state legislature, has referred readers to some of the more sagacious critics who do, including Paul Levy and Matt Murphy of State House News. [ Senate health cost bill moves forward, with critics, Boston Globe, May 19, 2012, at ]

    Apparently, much of the legislature shares Ms. Conaboy's confusion. She quotes Sen. Harriette Chandler (D, Worcester), saying, "It's a brilliant bill." It is, of course, anything but. Sen. Chandler is a dear, sweet person who has never been known as a thinker. The bills are mostly typical, lame General Court concoctions of vacuous posturing and more state bureaucracy.

    Ms. Conaboy might do better by calling up Alan Sager, director of the Health Reform Program at the Boston University School of Public Health. Prof. Sager has made a life career following just these topics. Most recently, in an article for the Boston Occupier, he stated clearly what the focus of effective cost control would have to be, writing, "Doctors' clinical decisions control almost 90 cents on the health care dollar." [ Hospital closings: Causes, consequences and responses, February 20, 2012, at ]

    The last Boston Globe article to make any sense of health-care costs was from business reporter Megan Woolhouse, a little over a year ago. She quoted both Prof. Sager and Prof. Stuart H. Altman, of Brandeis, saying that political attention remains focused on hot-button issues at the expense of root causes, particularly the cancerous growth of medical specialties at the expense of primary care. [ Pay may be hot issue, but other factors push harder on health costs, Boston Globe, March 13, 2011, at ]

    In that regard, perhaps the most enlightening part of Ms. Woolhouse's article was a comment from a reader known as "corfor1" [3/13/2011 10:18 AM EDT]:

    "I am a primary care doc and people like me could fix the whole health care system and deliver low cost high quality care. To do that I need time to spend with patients instead of writing long notes, filling out forms, and dealing with information systems that are decades behind what is possible.

    "I need to be able to stop worrying that I will be sued, censured, or reported when I tell people they don't need that test, consult, medicine, or other costly action. I need enough people on my team to intervene aggressively when people need to lose weight, quit smoking, take their medicine, and so on.

    "I need respect in my profession which means a system controlled by primary care docs and not specialists. The list goes on and on. None of this is happening and fewer and fewer people want to do what I do. I have given up on reforming the system and have accepted that all the stupidity that surrounds me is never going to change and will probably get worse."

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    Massachusetts tries another lemon squeeze

    So far, Massachusetts efforts aimed at reducing costs of medical care have not achieved much, and they stand little chance of better success in the future. The key mistakes of all the efforts so far are fiddling with payment systems and trying to recruit patients to act as a negotiators when they are sick.

    The main driver of medical costs, as almost everyone in medicine understands, is physicians' patterns of practice. Patients generally don't know what physicians know and are rarely able or willing to second-guess them. For decades now, most U.S. physicians have been trained, and most tend to practice, in heavily interventionist patterns. Complaints lead to tests; tests lead to diagnoses; and diagnoses lead to treatments, most often prescription drugs.

    Recently the Massachusetts Senate and House have generated bills that both, once again, try fiddling with payment systems and soliciting patients to act as negotiators. The latest twist in payment systems is the so-called "accountable care organization"--a variant of capitation, which was tried with hospitals in the 1970s and with HMO-type insurance plans in the 1980s, both times with little success. [ H.4070 and S.2260, available at ]

    The state has limited leverage: mainly Medicaid, because it manages the program and pays a large share of the costs and because recipients are poor and politically unconnected. The state can try demanding that physicians and hospitals join "accountable care" groups and refusing to pay if they don't. There may also be potential leverage from health-care plans for state employees and subsidized Commonwealth Care subscribers, but if those employees and subscribers became dissatisfied there would be political warfare.

    The main option for physicians and hospitals who don't want that approach is to refuse Medicaid patients and patients with state-sponsored insurance plans. Medicaid has very low and Medicare has low payment levels. Nationwide, about half of U.S. physicians are refusing Medicaid, and a quarter are refusing Medicare. [ Peter Cunningham, Physician reimbursemnt and participation in Medicaid, U.S. Payment and Access Commission, 2010, at ]