Preparing for a Changing Healthcare Marketplace Lessons from the Field (1993) / Chapter Skim
Currently Skimming:
The Role of States in Health Care Reform
The Role of States in Health Care Reform
Pages 78-105
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 78... ...
At the state level, a great number and range of health care reform agendas are now being developed and put into place. It is clear when looking across states that diversity necessitates an enormous degree of flexibility in approaches and implementation guidelines for any federally enacted reform.
|
From page 79... ...
process has kept occupancy rates in New York hospitals at 85 percent or better in the last seven or eight years, that occupancy rate is starting to driD downward and it is now in the mid-70s. We figure we have an excess of about 20 percent in our inpatient acute hospital beds, about ~ i,000 to be specific.
|
From page 80... ...
The second problem, poorly evaluated new tests and treatments, is a major contributor to the persistent and unacceptable rate of cost escalation in the health care sector. While everyone is concerned about the dollars we spend today on health care, an even more critical aspect of the cost problem is how rapidly costs rise.
|
From page 81... ...
I would argue that addressing these two cost problems is critical to reducing costs safely and getting a handle on how fast costs rise. Yet, if you look at the current debate on costs, very little attention is paid to these problems.
|
From page 82... ...
In terms of access, that means guaranteeing universal coverage and determining a financing mechanism. In New York state, we cannot afford to provide universal access to care to our 2.5 million uninsured on top of a Medicaid budget over $20 billion.
|
From page 83... ...
But we also have to come to grips with the fact that universal insurance coverage is not a guarantee that care will be universally accessible. The lack of primary care delivery capacity is probably the most important obstacle to achieving universal access to care.
|
From page 84... ...
It raises a lot of the issues that will arise in most major large states that have invested heavily in managed care as health care reform proceeds. Because we have not had universal access to care, those states that have invested heavily in providing health care services to the underserved have done so by creating a range of categorical programs and special providers.
|
From page 85... ...
The need for this service is declining rapidly. Many inpatient pediatric units across New York state function at very low occupancy rates.
|
From page 86... ...
The program relates to invasive cardiac procedures, particularly cardiac surgery. New York state's regulatory framework requires that every hospital that wants to have an invasive cardiac service, whether it be coronary angiography, angioplasty, or cardiac surgery, must apply through the certiD~cate-of-need (CON)
|
From page 87... ...
We do an analysis of the data, produce a risk adjustment of the operative mortality rate for bypass surgery, feed those data back to hospitals and cardiac surgery programs, an(l help them undertake very specific quality improvement activities to improve their outcomes. As a last step in that process, we publish the data annually.
|
From page 88... ...
I think states can take this kind of package and run with it to achieve the goals of health reform, and certainly in New York we may be better positioned than some to do so. As we progress with the current debate on health care reform we will see how close the national reform effort comes to achieving the goals I believe most important from the state perspective.
|
From page 89... ...
success stories would occupy as much time as this presentation, and wouicl be equally appropriate. The easiest feature of state capacity to talk about is fiscal capacity.
|
From page 90... ...
Now, I don't want you to think that that is a sign of the mean-spiritedness of the West. Rather, it sprang from the sense of limited fiscal capacity that we have in Colorado.
|
From page 91... ...
If we have the fiscal capacity, the states will be able to draw upon it. A third area of capacity that particularly stands in contrast to the state of New York, is regulatory capacity.
|
From page 92... ...
We are looking everywhere in the country at newly evolving vertically integrated health plans that are taking and bearing risk in very different ways than insurance companies and HMOs have historically done. The topic of quality anti how we measure quality and set standards for quality really raises the question of whether we have regulatory capacity.
|
From page 93... ...
It is curious to me that in a recent policy statement in favor of comprehensive national health care reform, the nation's governors called for national standards for insurance and tort reform. Now, of course, those are two areas of state law.
|
From page 94... ...
was mad at the governor because he had been a supporter for ColoradoCare, our proposal for comprehensive reform. When President Clinton got elected Governor Romer suggested that the state wait a little bit and let national reform proceed before we move ahead.
|
From page 95... ...
How do you define alliance boundaries? We are talking about something called community rating.
|
From page 96... ...
But I think the message that I want to leave you with today is that communities will have to be strong in having conversations with each other and willing to take on tough issues in order for any reform system to work. Just to bring this conversation full circle, let me go back to the first capacity question, the question of fiscal capacity.
|
From page 97... ...
One could argue that creating an elaborate mechanism to try to figure out which things work and which do not work to develop data, to decide about reimbursement, and so forth, while useful, is an enormous enterprise compared to the question of capitating care, for example, with the risk of underutilization but with the notion that physicians who don't have the incentive to do more for a variety of reasons try to reach a rational conclusions with patients. It seems to me that those are two very different ways of coming at the issue of control of costs.
|
From page 98... ...
We have to convince the American people that more health care is not always better health care, that in fact provision of inappropriate, unnecessary services conveys harm, and that doing nothing is very often the best course and provides the best outcome. That is a message that is very difficult to get across.
|
From page 99... ...
The governors talk a lot about the importance of flexibility in their program administration at the state level, and I think that is important given the variation in health systems around the country, but the fact is that the president's plan is really quite prescriptive in overall structure. Again, the number of laws that we would have to pass in Colorado to put it into place is not overwhelming.
|
From page 100... ...
We have now, I think, a 12-year tradition of having a legislative debate over health care reform every 3 years. The debate has taken place in the context of the hospital reimbursement legislation, but there have always been other issues that have come along, such as the primary care agenda, tort reform, medical education, and graduate medical education.
|
From page 101... ...
There are local markets that cross state boundaries, and a great concern as we look toward efficiency and a rational delivery system is what the states might do with all the good will, with diversity and limited capacity and limited fiscal resources. How do we deal with those issues?
|
From page 102... ...
That decision has to be federal, because of the need for uniformity, in part because of employer issues but even more importantly because of social issues. I would like to see that be the centerpiece of the reform effort and let the states implement according to the reform goals that are decided on a national basis.
|
From page 103... ...
That possibility certainly has fueled a fair amount of activity in New York, both on an ambulatory care basis and also on an inpatient basis, to try to make those institutions more competitive, more desirable for people when they have complete freedom to choose. Now, of course, under any scenario, no one expects that the underserved communities will have complete freedom of choice.
|
From page 104... ...
We are going out with a Medicaid mental health capitation contract and all of the community mental health centers in the state have come together so that they can submit a single bid. Just yesterday Denver Health and Hospitals announced that it had entered into a contractual agreement with a local
|
From page 105... ...
105 mood cam system to provide ~1 of the tea coca ice b, OI coma tboh ~n of expertise. So things me Bream happening.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.