People from other states would be wise to watch the sequence of events happening here in Massachusetts with regard to health insurance rates. As I described below:
Things are playing out just as one might predict in the Massachusetts small business and individual insurance market. The Insurance Commissioner turned down proposed rate increases, the state's insurers appealed to the courts, and now they can't write policies.
Now, Rob Weisman at the Boston Globe reports on yesterday's hearing in Suffolk Superior Court. The insurers argue that the action by the Insurance Commissioner is arbitrary and capricious, the traditional standard used to overturn a decision by a regulatory agency. The Division of Insurance argues, in part, that the insurers have not used up their administrative remedies before the agency, another traditional argument. A ruling is expected on Monday.
Meanwhile, columnist Scott Lehigh offers thoughts on "The State's great health care standoff," noting that "Unease is in the saddle in the state’s health care sector, and chaos looms on the horizon." He says,
Everyone is awaiting the next big political development. And here it is: Senate President Therese Murray will step into the breach when she speaks to the Greater Boston Chamber of Commerce Wednesday, unveiling a proposal she hopes will resolve the great health care standoff.
Senator Murray is a thoughtful and decisive person, and I, for one, look forward to her taking the reins here as many other elected and appointed official ignore the remarkable conclusions reached by the Attorney General. Just a few weeks ago, the AG issued a report, after months of study, in which she clearly explained that insurance price increases in the state were the result of two factors, the underlying increase in health care costs and a disparity of reimbursement rates that pay some providers substantially more than other providers. "Price variations are correlated to market leverage as measured by the relative market position of the hospital or provider group compared with other hospitals or provider groups within a geographic region or within a group of academic medical centers."
She also noted that the movement by some insurers and providers to capitated contracts did not result in a different growth rate in underlying medical costs from the traditional fee-for-service payment method. "Variations in providers’ per member per month expenses are not correlated to the methodology used to pay for health care, with expenses sometimes higher for globally paid providers than for providers paid on a fee-for-service basis."
In a comment below on one of my posts, astute observe Barry Carol offers the following thought. While he focuses on just one of the better paid hospital-doctor systems in his first paragraph, his second paragraph makes it clear that his approach could apply more broadly to others as well:
As I see it, the key problem from the insurers’ perspective is that employer customers felt it was absolutely essential to have Partners in their networks because that, presumably, is what the employees wanted. While narrow or limited network insurance products are quite well accepted in CA especially, it’s a different story in MA. Harvard Pilgrim, I believe, offered an insurance product that did not include Partners in the network but it didn’t gain much traction with customers.
This is why I keep coming back to disclosure of contract reimbursement rates and quality information to the extent that it’s measurable to help referring doctors steer their patients toward more cost-effective healthcare choices. I think that’s the best and most viable way to create countervailing power against Partners and other hospital systems with significant local or regional market power. Insurers could develop a mechanism to reward referring doctors who actually do this most effectively but they would need the price and quality information first. I think I know why insurers resist disclosure of contract rates but I don’t know why the regulators do.
To which I add one other thought in my comment on Scott's article:
Let's also look at the 10% of premiums used by the insurers for administrative costs, a percentage that has stayed remarkably steady over the years. As overall premiums have gone up, the number of dollars collected for non-medical costs has risen dramatically. Other financial services industries have been able to achieve improvements in their administrative and transaction-related expenses. Why has that not been possible in the health insurance field?
And just to make it clear that providers have a role, please review what I have said below about the potential for real quality improvement and cost savings to be achieved. An excerpt:
[I]t is possible for the participants in the health care system to accomplish major changes in the rate of medical cost inflation. Two articles have this theme. One is by Business Week's Catherine Arnst. The other is by Lucien Leape, Don Berwick, and others in Quality and Safety in Health Care. Both are worth reading, and they overlap in recommending several areas -- reducing infections and other preventable harm; empowering patients and families to participate in their care; and disclosing and apologizing for mistakes.
[T]here is a remarkable consensus on these items, and yet hospitals and doctors often fail to implement them. . . .
It is not unusual for industries facing structural change to be slow to move. Why? Because the leaders of those industries were promoted based on their success in the past financial, political, and social environment. They were hired for their ability to maintain the status quo, rather than for their ability to make change. Eventually, though, societal forces make themselves felt. If an industry does not adapt, the government will step in.
That is what we is happening right now in Massachusetts. Watch us closely, other 49! Do we go the route of short-term political expediency and bad regulatory policy, or do we show the wisdom and maturity to put in place directionally appropriate policies? There is an old legal expression: Hard cases make bad law. As things founder in the judicial and executive realms, brava to Senator Murray for having the courage to step in.
Friday, April 9, 2010
Thursday, April 8, 2010
A no-brainer
Jennifer Devine is a fellow at BIDMC in Cognitive Neurology. She writes:
I'm training for the Boston Marathon, as a fundraiser for AccesSport America, a Boston-based program that organizes sports programs for adults and children with disabilities. To attract attention to the cause, and to inform people about the role of exercise in the maintenance of overall health, I'm posting blogs on details of my research interest (exercise and cognition in brain injury) and various posts about my pre-medical life as an Olympic athlete. The latest post, "Your Brain on Exercise", is especially relevant to a general audience.
Please check this out and help Jennifer with her cause.
I'm training for the Boston Marathon, as a fundraiser for AccesSport America, a Boston-based program that organizes sports programs for adults and children with disabilities. To attract attention to the cause, and to inform people about the role of exercise in the maintenance of overall health, I'm posting blogs on details of my research interest (exercise and cognition in brain injury) and various posts about my pre-medical life as an Olympic athlete. The latest post, "Your Brain on Exercise", is especially relevant to a general audience.
Please check this out and help Jennifer with her cause.
Catch this (fish)
I know I am playing into the hands of two commercial enterprises, one of which I patronize (with pleasure!) and one of which I know hardly at all. By repeating this, I am helping them go viral, but I think they deserve it because of the creativity they show. Here's the letter:Hi Paul,
Our client, Legal Sea Foods Restaurants, wanted to spread the word that no one has fresher fish than they have.
We wanted to do something unexpected that makes the point and gets some buzz going.
As one of their restaurants is adjacent to the Boston Aquarium, we opportunistically placed a sign for the restaurant right next to the direction signage to the aquarium.
We made these signs and actually put them up.
Yes, a bit of a stunt, but strategically right on the money. That's the kind of work we like to do.
Best,
Kristen Czyzak
DeVito/Verdi
New York, NY
Wednesday, April 7, 2010
Sarah and Amy get acquainted
OK, this is not a big deal in some ways, but it is a nice story about communication between the academic staff and the administrative staff in our hospital. I like what this email exchange stands for -- environmental concerns, staff concerns, safety issues, etc., but especially the respect that our folks show to one another.
To whom it may concern,
My name is Sarah, and I have been here for three years as a researcher in the Neurology department in Palmer 127. I bike here to BIDMC everyday from Somerville, which takes about half an hour, rain or shine, blizzard or intense heat. For the majority of the time I have been here, I have locked my bike outside the railings of the Farr building (directly across the street from the emergency room in the West Campus). Last week, however, I received a note from public safety notifying me to lock my bike elsewhere because it is a hazard to lock my bike along the railings outside of Farr.
For the most part, I do not see how my bike being locked there can be a hazard. It is merely an exit—and not even the main exit—and not many people traverse that way. The part that bothers me more however was that public safety suggested I lock my bike in one of the garages instead. I tend to work late and not leave until well after dark, and as a woman, I am incredibly anxious about walking into a garage alone when most people have already left. For this, I find it unsettling and ironic that public safety suggest I lock my bike in the garage. If they are indeed concerned about my safety, they would have suggested otherwise.
Prior to construction work right outside of the Farr building entrance, there used to be bike racks opposite of the Farr building entrance. While these racks were not sufficient during the heart of summer when most people chose to bike here, they provided additional spaces to lock bikes. The majority of them have since been removed a few months ago when construction took place there.
I merely ask that these bike racks be put back where they were (opposite the main Farr entrance). Barring that and my desire to not lock my bike in the garage, is there another area relatively open and near the Farr building where I can lock my bike if public safety feels that I cannot lock it outside the railings of Farr?
As a hospital and health institution, I hope BIDMC supports those who wish to promote a healthy lifestyle by biking. I do not believe that placing the bike racks back where they were would intrude on anything.
Thank you for your time and consideration,
Sarah
Hi Sarah,
Thank you for your email. It was both timely and helpful. As someone trying to encourage more employees to ride to work, I want to thank you for continuing to do so.
I understand your frustration with having the racks in front of the Farr Building moved so I want to first explain why we needed to do that. Earlier this year the hospital began a series of projects designed to make the facilities more accessible to patients with a variety of disabilities. As I have begun looking for more rack locations I have learned that what looks like plenty of space to a biker is often not enough clearance to a wheelchair or false information to a blind person navigating a railing with their hands. We attempted to communicate the reason for the relocation via the portal and an email to managers but it is clear that we did not succeed in reaching everyone so I want to apologize for that.
When I learned that the racks needed to be relocated my priority was to find safe sheltered spots that could serve as a fair substitute for the spaces being lost across from the Farr entrance. I ruled out several locations that did not pass my "5 '2" female leaving alone after dark" test. We decided to put them in the garages because there are parking garage attendants in both West Campus garages. In LMOB the racks are right next to the booth and has the added of advantage of being accessible directly from the building. In Pilgrim, you need to walk by the booth to get to your bike. Since you are one of our hardy cyclists who ride, regardless of weather, I hope you will feel comfortable using the garage spaces, particularly on days when you want to protect your bike from the weather.
That said, we share your expectation that bike traffic will increase as the weather warms up so Chief Casey has been working for awhile to get more racks added. Space is a challenge, but we have identified a few spots in well let areas closer to some entrances so we hope to have some racks installed soon.
A similar email exchange with a bike commuter last week was really helpful in changing the criteria I was using to find additional spots. Doing so opened up a few more options, so please feel free to contact me both with any questions about this email or any thoughts for alternative locations.
Thanks!
-Amy Lipman, BIDMC Environmental Sustainability Coordinator
Dear Amy,
I would like to thank you very much for your quick response. It is really great to work at a place where people (especially the executives at the top) take your concerns seriously and try to implement a solution right away. I think that is thoughtful and wonderful and though I have limited experience with the customs here in the U.S. (I am from Switzerland and have spent a total of three years here), I am almost certain that this is a sign of the openness and community of BIDMC. I am very grateful for that.
That being said, I have thought about the bike racks again and have three suggestions for possible locations. Though these locations may not be the most viable, I am merely keeping the conversation open and exchanging ideas:
1) How about replacing the parking spots opposite to the Farr entrance with bike racks? Hardly any handicapped people get out there and most people park right in front of the entrance, along the sidewalk anyway.
2) How about racks in front of the Main entrance of the West Clinical Center (similar to the racks in front of the Joslin Diabetes Center)? There is plenty of space - again especially for the cars - and some of that could be yielded for bicyclists? Or even under the awning, there would probably be some space for both pedestrians and bikes.
3) How about converting some space in the emergency room parking lot? While there is no overhead sheltering, space is abundant and seem like a decent place to lock some bikes.
I know by now that cars are really important to Americans and that it is just normal for them to put the car anywhere. While I understand everybody would like to be in front of the main entrance, arguing for bicyclists, I think it’d better if such spaces could be shared between bicyclists and motorists?
I apologize for being bold, and I don't mean to offend anybody. I am grateful for the opportunity to openly share my concerns and suggestions. Thank you!
Best,
Sarah
Hi Sarah,
Thanks for your thoughtful response and your ideas. Even if we can't put racks in the exact locations you suggested, hearing your suggestions helps us understand priorities as we look for places that can work. It sounds like the closer to the building entrance the better. Sheltered spots are helpful, but you'd be willing to trade shelter for proximity. This priority list echoes that of a second bike commuter who sent me some suggestions. Initially we prioritized sheltered spots, resulting in covered spaces far from main entrances. For the next set of racks we are going to prioritize proximity to building entrances.
In response to the specific locations you suggested, I am afraid they won't work, so I wanted to quickly explain why. As I walked past MIT last night I couldn't help but notice all the of bike racks lined up under major buildings, some of them running the length of the building, and all of them filled almost to capacity. The sight of them made me jealous. Most of the people I interact with are the 7,000 or so healthy employees who come in and out of here every day. Many of them are trying to find greener ways to get to work. However, as a hospital, our primary mission is to treat people who aren't 100% healthy. This means we need to share our streets, sidewalks and entrances with patients, many of whom are here to treat conditions that limit their mobility or who have received treatments that temporarily impede their mobility. Add the challenge of being on 2 sides of a busy street and we find ourselves much more reliant on motorized transportation than a place like MIT or typical office building that caters to a vibrant healthy population. This means that we need to a decent amount of car access available for ambulances, patient drop-off and shuttles. Like handicapped spaces in a parking lot, the key here is that they have to be available even if they are underutilized.
While we can't put racks in any of the places you suggested, we have identified places that I hope will be almost as good. The rack in Lowry that was installed incorrectly is going to be moved outside the Deaconess building on the concrete slab next to the entrance to public safety. My hope is that it will serve the bikes that can't find space on the racks under the bridge. It isn't sheltered but both you can see both the WCC and Farr entrances from it. We are hoping to have this moved on Monday.
If we are able to purchase more racks for the West Campus, the plan is to install them to the left of the WCC entrance. There are two jogs in the building, just past the shuttle stop, that give us enough extra sidewalk space to put bike racks.
Thanks again for thoughts and suggestions. I look forward to your feedback on the new locations.
-Amy
To whom it may concern,
My name is Sarah, and I have been here for three years as a researcher in the Neurology department in Palmer 127. I bike here to BIDMC everyday from Somerville, which takes about half an hour, rain or shine, blizzard or intense heat. For the majority of the time I have been here, I have locked my bike outside the railings of the Farr building (directly across the street from the emergency room in the West Campus). Last week, however, I received a note from public safety notifying me to lock my bike elsewhere because it is a hazard to lock my bike along the railings outside of Farr.
For the most part, I do not see how my bike being locked there can be a hazard. It is merely an exit—and not even the main exit—and not many people traverse that way. The part that bothers me more however was that public safety suggested I lock my bike in one of the garages instead. I tend to work late and not leave until well after dark, and as a woman, I am incredibly anxious about walking into a garage alone when most people have already left. For this, I find it unsettling and ironic that public safety suggest I lock my bike in the garage. If they are indeed concerned about my safety, they would have suggested otherwise.
Prior to construction work right outside of the Farr building entrance, there used to be bike racks opposite of the Farr building entrance. While these racks were not sufficient during the heart of summer when most people chose to bike here, they provided additional spaces to lock bikes. The majority of them have since been removed a few months ago when construction took place there.
I merely ask that these bike racks be put back where they were (opposite the main Farr entrance). Barring that and my desire to not lock my bike in the garage, is there another area relatively open and near the Farr building where I can lock my bike if public safety feels that I cannot lock it outside the railings of Farr?
As a hospital and health institution, I hope BIDMC supports those who wish to promote a healthy lifestyle by biking. I do not believe that placing the bike racks back where they were would intrude on anything.
Thank you for your time and consideration,
Sarah
Hi Sarah,
Thank you for your email. It was both timely and helpful. As someone trying to encourage more employees to ride to work, I want to thank you for continuing to do so.
I understand your frustration with having the racks in front of the Farr Building moved so I want to first explain why we needed to do that. Earlier this year the hospital began a series of projects designed to make the facilities more accessible to patients with a variety of disabilities. As I have begun looking for more rack locations I have learned that what looks like plenty of space to a biker is often not enough clearance to a wheelchair or false information to a blind person navigating a railing with their hands. We attempted to communicate the reason for the relocation via the portal and an email to managers but it is clear that we did not succeed in reaching everyone so I want to apologize for that.
When I learned that the racks needed to be relocated my priority was to find safe sheltered spots that could serve as a fair substitute for the spaces being lost across from the Farr entrance. I ruled out several locations that did not pass my "5 '2" female leaving alone after dark" test. We decided to put them in the garages because there are parking garage attendants in both West Campus garages. In LMOB the racks are right next to the booth and has the added of advantage of being accessible directly from the building. In Pilgrim, you need to walk by the booth to get to your bike. Since you are one of our hardy cyclists who ride, regardless of weather, I hope you will feel comfortable using the garage spaces, particularly on days when you want to protect your bike from the weather.
That said, we share your expectation that bike traffic will increase as the weather warms up so Chief Casey has been working for awhile to get more racks added. Space is a challenge, but we have identified a few spots in well let areas closer to some entrances so we hope to have some racks installed soon.
A similar email exchange with a bike commuter last week was really helpful in changing the criteria I was using to find additional spots. Doing so opened up a few more options, so please feel free to contact me both with any questions about this email or any thoughts for alternative locations.
Thanks!
-Amy Lipman, BIDMC Environmental Sustainability Coordinator
Dear Amy,
I would like to thank you very much for your quick response. It is really great to work at a place where people (especially the executives at the top) take your concerns seriously and try to implement a solution right away. I think that is thoughtful and wonderful and though I have limited experience with the customs here in the U.S. (I am from Switzerland and have spent a total of three years here), I am almost certain that this is a sign of the openness and community of BIDMC. I am very grateful for that.
That being said, I have thought about the bike racks again and have three suggestions for possible locations. Though these locations may not be the most viable, I am merely keeping the conversation open and exchanging ideas:
1) How about replacing the parking spots opposite to the Farr entrance with bike racks? Hardly any handicapped people get out there and most people park right in front of the entrance, along the sidewalk anyway.
2) How about racks in front of the Main entrance of the West Clinical Center (similar to the racks in front of the Joslin Diabetes Center)? There is plenty of space - again especially for the cars - and some of that could be yielded for bicyclists? Or even under the awning, there would probably be some space for both pedestrians and bikes.
3) How about converting some space in the emergency room parking lot? While there is no overhead sheltering, space is abundant and seem like a decent place to lock some bikes.
I know by now that cars are really important to Americans and that it is just normal for them to put the car anywhere. While I understand everybody would like to be in front of the main entrance, arguing for bicyclists, I think it’d better if such spaces could be shared between bicyclists and motorists?
I apologize for being bold, and I don't mean to offend anybody. I am grateful for the opportunity to openly share my concerns and suggestions. Thank you!
Best,
Sarah
Hi Sarah,
Thanks for your thoughtful response and your ideas. Even if we can't put racks in the exact locations you suggested, hearing your suggestions helps us understand priorities as we look for places that can work. It sounds like the closer to the building entrance the better. Sheltered spots are helpful, but you'd be willing to trade shelter for proximity. This priority list echoes that of a second bike commuter who sent me some suggestions. Initially we prioritized sheltered spots, resulting in covered spaces far from main entrances. For the next set of racks we are going to prioritize proximity to building entrances.
In response to the specific locations you suggested, I am afraid they won't work, so I wanted to quickly explain why. As I walked past MIT last night I couldn't help but notice all the of bike racks lined up under major buildings, some of them running the length of the building, and all of them filled almost to capacity. The sight of them made me jealous. Most of the people I interact with are the 7,000 or so healthy employees who come in and out of here every day. Many of them are trying to find greener ways to get to work. However, as a hospital, our primary mission is to treat people who aren't 100% healthy. This means we need to share our streets, sidewalks and entrances with patients, many of whom are here to treat conditions that limit their mobility or who have received treatments that temporarily impede their mobility. Add the challenge of being on 2 sides of a busy street and we find ourselves much more reliant on motorized transportation than a place like MIT or typical office building that caters to a vibrant healthy population. This means that we need to a decent amount of car access available for ambulances, patient drop-off and shuttles. Like handicapped spaces in a parking lot, the key here is that they have to be available even if they are underutilized.
While we can't put racks in any of the places you suggested, we have identified places that I hope will be almost as good. The rack in Lowry that was installed incorrectly is going to be moved outside the Deaconess building on the concrete slab next to the entrance to public safety. My hope is that it will serve the bikes that can't find space on the racks under the bridge. It isn't sheltered but both you can see both the WCC and Farr entrances from it. We are hoping to have this moved on Monday.
If we are able to purchase more racks for the West Campus, the plan is to install them to the left of the WCC entrance. There are two jogs in the building, just past the shuttle stop, that give us enough extra sidewalk space to put bike racks.
Thanks again for thoughts and suggestions. I look forward to your feedback on the new locations.
-Amy
It's easier to beat up the insurers
Things are playing out just as one might predict in the Massachusetts small business and individual insurance market. The Insurance Commissioner turned down proposed rate increases, the state's insurers appealed to the courts, and now they can't write policies.
Meanwhile, policy-makers ignore the underlying causes of the problem:
Just a few weeks ago, the Attorney General issued a report, after months of study, that explained that insurance price increases in the state were the result of two factors, the underlying increase in health care costs and a disparity of reimbursement rates that paid some providers substantially more than other providers.
As noted by my colleague Ellen Zane, in remarks consistent with the findings of the AG, "The funneling of dollars disproportionately among hospital and provider groups serves to warp the overall system balance."
Taking a page from the debate on national health care, local officials seem to have decided that it is easier to beat up on the unpopular insurance companies rather than address the root cause of the problems. Here, though, the insurers are non-profits. If they are forced to charge prices below those that are based on actuarial determinants, there are no shareholders to absorb the losses. The most direct result is a reduction in capital reserves, a key metric the Division of Insurance is statutorily charged to protect.
Meanwhile, policy-makers ignore the underlying causes of the problem:
Just a few weeks ago, the Attorney General issued a report, after months of study, that explained that insurance price increases in the state were the result of two factors, the underlying increase in health care costs and a disparity of reimbursement rates that paid some providers substantially more than other providers.
As noted by my colleague Ellen Zane, in remarks consistent with the findings of the AG, "The funneling of dollars disproportionately among hospital and provider groups serves to warp the overall system balance."
Taking a page from the debate on national health care, local officials seem to have decided that it is easier to beat up on the unpopular insurance companies rather than address the root cause of the problems. Here, though, the insurers are non-profits. If they are forced to charge prices below those that are based on actuarial determinants, there are no shareholders to absorb the losses. The most direct result is a reduction in capital reserves, a key metric the Division of Insurance is statutorily charged to protect.
I see a salad, so I choose the fries
I was talking with the MBA students at Duke's Fuqua School of Business about the obesity epidemic in the United States, and they told me about some interesting research published last year. Gavin Fitzsimons, professor of marketing and psychology, and his colleagues describe an effect called "vicarious goal fulfillment." Excerpts:In a lab experiment, participants possessing high levels of self-control related to food choices (as assessed by a pre-test) avoided french fries, the least healthy item on a menu, when presented with only unhealthy choices. But when a side salad was added to this menu, they became much more likely to take the fries.
... Although fast-food restaurants and vending machine operators have increased their healthy offerings in recent years, “analysts have pointed out that sales growth in the fast-food industry is not coming from healthy menu items, but from increased sales of burgers and fries,” Fitzsimons said. “There is clearly public demand for healthy options, so we wanted to know why people aren’t following through and purchasing those items.”
An abstract of the article from the Journal of Consumer Research is available here. (You will need a subscription to read the full text.) Here's another quote from the news story:
“[T]he presence of a salad on the menu has a liberating effect on people who value healthy choices,” Fitzsimons said. “We find that simply seeing, and perhaps briefly considering, the healthy option fulfills their need to make healthy choices, freeing the person to give in to temptation and make an unhealthy choice. In fact, when this happens people become so detached from their health-related goals, they go to extremes and choose the least healthy item on the menu.”
Readers, is this what you do? Does this ring true?
Tuesday, April 6, 2010
Blue Devils fans
Fortunately, my presentation at Duke's Fuqua School of Business did not conflict today with the celebration at Cameron Indoor Stadium welcoming back the victorious men's NCAA championship team. If it had, no one would have come. But as you can see from these pictures, many of the students came from that event in appropriate attire.
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