Five disgruntled Republican physicians and one nurse warmed up the conference room at a Hilton DoubleTree hotel in Pennsylvania yesterday. All were members of the U.S. Congress, gathered for a rally that Donald Trump would call “a meeting talking about health care.”
On the day that health-insurance enrollment began for 2017, the Trump campaign chose to keep the focus on medicine. Health-insurance premiums will be increasing in exchanges for some two to five percent of Americans this year. The U.S. has the most expensive health-care system in the world and needs a great deal of improvement. The candidate has been hostile toward the current health-care system and toward Hillary Clinton’s proposals, but has offered almost nothing in the way of solutions. Perhaps today was the day for a plan.
First to the mic stepped John Barrasso, an orthopedic surgeon from Wyoming. “People need a better way, and that is why we are here,” he said, setting the stage. “There is a better way than Obamacare.” He said that he believes that “government is the problem” and that Hillary Clinton is proposing “more Obamacare,” though it was unclear what part of the system he was referring to. “Republicans are here today to offer solutions,” he said.
Before he could get into those solutions, he introduced another orthopedic surgeon, Tom Price of Georgia.
“We want a system that’s affordable for everybody, that’s accessible for everybody, that’s of the highest quality, and provides choices for patients—all of those things have been destroyed by Obamacare,” Price said. “This is what happens when you put the government in charge,” he continued (although the U.S. health-care system is run by insurance companies, pharmaceutical companies, and hospital consortia).
So, the surgeon offered, we need Donald Trump and Mike Pence “to put in place a real health solution. That solution exists. We’ve been working on that solution for years, literally.”
A promising note, which he used as a segue to introduce gynecologist Mike Burgess of Texas.
Burgess said we need to repeal Obamacare. He said that Obamacare collapses “the market.” The elaborate law “tells you what you have to buy.” (Obamacare created a marketplace for health care to attempt to encourage competition among insurance companies.) “When did more federal money going into anything ever result in a cheaper price to the consumer?” he asked. No one raised a hand to mention all the Americans on Medicare and Medicaid, and the millions receiving subsidies to purchase insurance in the free market using exchange websites.
With that he introduced anesthesiologist Andy Harris of Maryland, who said that he’s tired of hearing his patients complain about Obamacare. “It’s going to get worse. The only solution is—” he paused for another hopeful moment,“Trump Pence.”
So close that time.
Then Harris introduced nurse Renee Ellmers from North Carolina. “We’ve got to defeat this,” she said, apparently referring to the entire system established by the Affordable Care Act. She acknowledged that President Obama likened the current law to a starter home. “Well, you know what? If it’s a house, it’s an outhouse.”
The audience and others on stage laughed and applauded. An outhouse.
“And, yes, Hillary Clinton only wants to make it worse,” she continued. “How many of you have been to a doctor and felt like the doctor spent more time on the computer than taking care of you?” she said, referring to electronic medical records. “That’s Obamacare. We’re here to support Donald Trump and Mike Pence because we know that they are the answer.”
With that she introduced another doctor from Tennessee, representative Scott DesJarlais. “I got a message for Barack Obama and Hillary Clinton,” he said. “Obamacare is going to fail, period.” The nurse, Ellmers, behind him jumped and clapped as she shouted, “Yes!”
He went on to call Obamacare “a gateway to socialized medicine.”
Then he introduced Cynthia Lummis, a representative from Wyoming, who is not a health-care professional, but does have an undergraduate degree in animal science. “When the government tells the American people ‘this is how you’re going to live your life,’ Americans get angry,” she added.
Then Price came back to the mic to build the energy to a climax, drawing the crowd into a chant: Trump! Trump! Trump!
Then 20 minutes passed.
Then Ben Carson wandered on stage.
He talked about how he was once a neurosurgeon nearby, in Baltimore. He said that Trump’s success in the hotel industry bodes well for his success in health care. We need to drain the swamp and tell the people in the government, “You’re fired!” Much applause.
He then introduced Mike Pence. Pence said that Carson was “one of the great leaders of the United States of America,” without explanation. Pence said that he considers himself a Christian, a conservative, and a Republican—in that order. He furrowed his brow and waited for applause. He emphasized that Donald Trump is a man who doesn’t quit. “We’re going to make him the next president of the United States of America!” A standing ovation. “We’re going to lower taxes across the board,” he said. He offered that he would “end the war on American energy.” He said they would “end illegal immigration once and for all.”
Then he said it: “We’re going to repeal and replace Obamacare.”
He said that the health law is “plain and simple, a government takeover of health care,” referring to the individual mandate and subsidies. He said he’s very proud that not one Republican in Congress voted for Obamacare. Applause for partisanship. He mentioned “free-market solutions.” Then he said the polls looked good for Trump, and he is going to win. The people stood and chanted “Trump! Trump! Trump!” He said “repeal and replace” again. “This government takeover of health care called Obamacare is failing in states across America,” Pence said.
Then he talked about premiums increasing. He furrowed his brow and shook his head. He said that right here in Pennsylvania, people would “see their rates spike drastically with absolutely no help from the government.” He furrowed his brow. At this point it was unclear if help from the government was good or bad.
“Hillary Clinton’s plan is actually to introduce what’s called single-payer into the system,” he said, falsely. “More government-run health care.”
Then he said he was going to pull Obamacare off the market so it would stop burning up everyone’s wallets. A standing ovation.
“Part of the reasons costs went up is because Obamacare dictates that Americans buy a government-designed health care plan,” he said, falsely.
Then he said Obamacare is killing jobs, although unemployment in the U.S. is lower than it was in the years before the law.
“It’s time to end this government takeover of healthcare and start over with American solutions,” he said. “We’re going to repeal Obamacare—lock, stock, and barrel.” A standing ovation.
He said that he would use the free market, the American way. He mentioned allowing health insurance to be purchased across state lines, which is one of two concrete ideas that Trump and Pence have offered. The other is to make it easier for people to open savings accounts to pay for their own health care when they get sick (“health savings accounts”). “They allow you to control your health care dollars,” Pence said. Indeed they do, and many large employers already offer this option.
He also said he would empower Americans with more information about the cost and quality of care in their hometowns. This would be great and is an element of Obamacare as well, though it has proven difficult for the government to force this transparency. Pence offered no plan to accomplish this. Theoretically when everyone is paying cash for their medical care, providers will compete aggressively to offer the lowest prices, with billboards and subway ads. The wealthiest people will get the most care.
Then he offered another thing that’s part of Obamacare, also without a plan: “Donald Trump and I will protect Americans with pre-existing conditions so that they’re not charged more or denied treatment just because they’ve been sick. As long as they pay their premiums consistently,” he said, which is how insurance works. In this case, as long as a person has enough money in their (health) savings account to pay for exorbitant health insurance (that they might have to pay because of a pre-existing condition), he and Trump will support that person.
“We didn’t see these rate increases when the states were running things,” he said, falsely. “So we’re going to empower the states, once again, to manage our health insurance industry.”
He said Clinton would offer “more Obamacare” which was “a government takeover of health care from the start,” and that he would like a system based on “free market principles.” Then he said we need a health-care system based on “free market principles and consumer choice,” and then he furrowed his brow and said “it’s time to come home.”
Then everyone stood up and applauded. Then Pence introduced the man who would “restore freedom to our health-care economy,” Donald Trump. As he walked on stage, I couldn’t see anyone in the audience who wasn’t taking a picture. “The Star-Spangled Banner” played. Trump said that a lot of people were “enthused and excited” about his campaign. He said that Ben Carson would be “very much involved” with his administration.
He said he will immediately “repeal and replace Obamacare.” He then said he would ask Congress to convene “a special session, so we can repeal and replace.” Congress will be in session already in January. “Obamacare has to be replaced,” he said, “it is a catastrophe.” He said, falsely, that Clinton “wants to put the government totally in charge of health care in America. If we don’t repeal and replace Obamacare, we will destroy American health care forever.”
The people stood and chanted “Trump! Trump! Trump!”
He repeated what Pence said, that he would like to have people use health savings accounts, where they save money tax-free that can be used to pay for health care. “It will be a much better health care [sic] at a much less expensive cost.”
It won’t be, though. When everyone pays for their own health care individually, they lose collective purchasing power and the pharmaceutical companies and hospital systems can charge whatever they want, offering care to only those who can afford high costs.
Then Trump took a hard right turn, and with the rest of his twenty minutes, he talked about bringing back manufacturing jobs, China, NAFTA, great negotiating, Mexico, currency manipulation, “clean coal,” steel-workers’ jobs being stolen by China, more choices for school for children, “bringing education local” [standing ovation], tax cuts, rebuilding the military [standing ovation], that we are “far less safe today than we were before we started,” vocational training, the fact that he went to Wharton, African Americans in the inner cities, and the enthusiasm of crowds at his rallies.
In Jacob S. Hacker’s call for a public option to compete with private insurers in Obamacare, he compares it favorably to the current competition between traditional Medicare and private Medicare Advantage plans. But he does not acknowledge that Medicare Advantage plans are paid more per enrollee than the same people would cost in traditional Medicare, because the private plans market to younger and healthier senior citizens.
Thus, taxpayers subsidize Medicare Advantage plans. It is likely that the same thing would happen with a public option: The private insurers would attract healthier customers, leaving sicker patients to the public plan.
It would be better simply to extend Medicare to everyone over 55; the additional expenditures would be more than offset by savings in premiums and out-of-pocket costs.
MARCIA ANGELL
Cambridge, Mass.
The writer is a former editor in chief of The New England Journal of Medicine.
by Hader Javek Warraich - DURHAM, N.C. — Out of nowhere, a patient I recently met in my clinic told me, “If my heart stops, doctor, just let me go.”
“Why?” I asked him.
Without hesitating, he replied, “Because there are worse states than death.”
Advances in medical therapies, in addition to their immense benefits, have changed death to dying — from an instantaneous event to a long, drawn-out process. Death is preceded by years of disability, countless procedures and powerful medications. Only one in five patients is able to die at home. These days many patients fear what it takes to live more than death itself.
That may explain why this year, behind the noise of the presidential campaign, the right-to-die movement has made several big legislative advances. In June, California became the fifth and largest state to put an assisted suicide law into effect; this week the District of Columbia Council passed a similar law. And on Tuesday voters in Colorado will decide whether to allow physician-assisted suicide in their state as well.
Yet even as assisted suicide has generated broader support, the group most vehemently opposed to it hasn’t budged: doctors.
That resistance is traditionally couched in doctors’ adherence to our understanding of the Hippocratic oath. But it’s becoming harder for us to know what is meant by “do no harm.” With the amount of respirators and other apparatus at our disposal, it is almost impossible for most patients to die unless doctors’ or patients’ families end life support. The withdrawal of treatment, therefore, is now perhaps the most common way critically ill patients die in the hospital.
While “withdrawal” implies a passive act, terminating artificial support feels decidedly active. Unlike assisted suicide, which requires patients to be screened for depression, patients can ask for treatment withdrawal even if they have major depression or are suicidal. Furthermore, withdrawal decisions are usually made for patients who are so sick that they frequently have no voice in the matter.
Some doctors skirt the question of assisted suicide through opiate prescriptions, which are almost universally prescribed for patients nearing death. Even though these medications can slow down breathing to the point of stoppage, doctors and nurses are very comfortable giving them, knowing that they might hasten a “natural” death.
In extreme cases, when even morphine isn’t enough, patients are given anesthesia to ease their deaths. The last time I administered what is called terminal sedation, another accepted strategy, was in the case of a patient with abdominal cancer whose intestines were perforated and for whom surgery was not an option. The patient, who had been writhing uncontrollably in pain, was finally comfortable. Yet terminal sedation, necessary as it was, felt closer to active euthanasia than assisted suicide would have.
While the way people die has changed, the arguments made against assisted suicide have not. We are warned of a slippery slope, implying that legalization of assisted suicide would eventually lead to eugenic sterilization reminiscent of Nazi Germany. But no such drift has been observed in any of the countries where it has been legalized.
We are cautioned that legalization would put vulnerable populations like the uninsured and the disabled at risk; however, years of data from Oregon demonstrate that the vast majority of patients who opt for it are white, affluent and highly educated.
We are also told that assisted suicide laws will allow doctors and nurses to avoid providing high-quality palliative care to patients, but the data suggests the opposite: A strong argument for legalization is that it sensitizes doctors about ensuring the comfort of patients with terminal illnesses; if suicide is an option, they’ll do what they can to preclude it.
And, again, we are counseled that physicians should do no harm. But medical harm is already one of the leading causes of death — and in any case, isn’t preventing patients from dying on their terms its own form of medical harm?
With the right safeguards in place, assisted suicide can help give terminally ill patients a semblance of control over their lives as disease, disability and the medical machine tries to wrest it away from them. In Oregon, of the exceedingly few patientswho have requested a lethal prescription — 1,545 in 18 years — about 35 percent never uses it; for them, it is merely a means to self-affirmation, a reassuring option.
Instead of using our energies to obfuscate and obstruct how patients might want to end their lives when faced with life-limiting disease, we physicians need to reassess how we can help patients achieve their goals when the end is near. We need to be able to offer an option for those who desire assisted suicide, so that they can openly take control of their death.
Instead of seeking guidance from ancient edicts, we need to re-evaluate just what patients face in modern times. Even if it is a course we personally wouldn’t recommend, we should consider allowing it for patients suffering from debilitating disease. How we die has changed tremendously over the past few decades — and so must we.
At least a quarter of all employers, and well over half of large employers, are offering their workers a choice of a high-deductible health plan, according to Mercer, a benefits consultant. This is the time of year when many employers ask you to sign up for health insurance, so if you are going to take the high-deductible plunge, here are some things to consider:
How High Is High?
The days of having a health plan that covers all out-of-pocket costs are largely gone. Even H.M.O. plans, which require you to go to a doctor or hospital within a specific network, may require you to meet a deductible before your coverage kicks in.
There is no precise definition of a high-deductible plan, but it is widely considered to be a plan that is paired with a special savings account and with a deductible of at least $1,300 for an individual and $2,600 for a family. There are often different deductibles covering your prescriptions, a hospital stay or an emergency visit, as well as more routine care.
The Affordable Care Act sets annual limits on how much employees can be expected to pay out of their own pockets. In 2017, an individual is responsible for as much as $7,100, and families face a cap of $14,300.
Savings and Cash Flow
If you have saved the paperwork from your insurer from previous years, you may be able to get a pretty good sense of how much you might typically spend, barring a medical emergency.
If you really don’t have the money to pay for even minor medical emergencies, like an unexpected trip to a specialist, an expensive blood test or an M.R.I., you should think twice about a high-deductible plan.
Also factor in a health savings account. That can help offset the out-of-pocket costs. These accounts can accumulate funds tax-free, you can often invest the money and use it for a medical rainy day in the distant future. And some employers even pitch in $500 or $1,000 to the account.
Free Is Free
Make sure to figure out what services are covered with no out-of-pocket costs. Some primary care doctor visits, for example, or preventive procedures like colonoscopies or a flu shot can be fully covered.
A Call to Save Money
Companies are increasingly offering telemedicine services as part of a health plan or as an additional benefit. These virtual consultations, by phone or through a computer, may be a good alternative to a more expensive visit to the doctor or the urgent care center around the corner.
Be a Smart Shopper
One of the main ideas behind the idea of a high deductible plan is to make the employee a smarter shopper because personal money is on the line. There can be tremendous variations in the price of an M.R.I. or going to a dermatologist, and doing some comparison shopping could save you money.
But it can be impossible to get a hospital or doctor, or even your insurer, to give you a straight answer about what something might cost. Still, many insurers now offer shopping tools on their websites so it makes sense to check them out to see if you can find a less expensive option.
California’s Prop. 61 Offers Opportunity to Take on Big Pharma
by RoseAnn DeMoro - Common Dreams
While the world is watching the Presidential race Tuesday night, another election battle in California provides a window in the ability of voters to challenge corporate power – in this case one of the most abusive industries in the world, big pharma.
Proposition 61 in California pits the drug cartel and those shilling for it, against patients, nurses, and consumer advocates. At a time when the drug giants have buried proposals in Congress and state legislatures to block any restraints on its predatory pricing, Prop. 61 would actually begin the process of lowering prices.
The drug corporations are running scared. They’ve poured in over $120 million, the most ever spent on a California ballot measure (and likely the most ever in the U.S.) with a non-stop pounding of deceptive and misleading ads intended to bully voters the way they routinely intimidate lawmakers.
Some of the tactics are right out of the playbook the industry has used across the country. As veteran national healthcare writer Trudy Lieberman notes, “PhRMA has reaped big dividends from having patient advocacy organizations shill for it in the legislative and regulatory arenas.”
With Prop. 61, the drug companies rarely speak in their own name, hiding their opposition role behind others viewed to have more public credibility. The Interceptcites public filings that reveal “19 different civic organizations, from the Foreign Legion to a bilingual voter guide organization, taking drug industry funds and endorsing No on Prop 61.”
Among them are several LGBT Democratic clubs whose influence has helped neutralize some liberal to progressive potential supporters, and prominent veterans organizations, all of whom have received drug industry funding.
Additionally, big pharma has lined up most of the corporate news media with Trudy Lieberman caustically noting after reading many editorials and op eds, “I concluded they must have been written from drug industry talking points dropped off at the newspaper offices.”
Yet, in the face of the massive onslaught of ads, every time you turn on your TV, computer, or mobile device, Prop. 61 has held its own with voters, polls have shown, and has a real chance to win.
That’s what has the drug companies alarmed. Sen. Bernie Sanders, who has embraced Prop. 61 in videos, billboard ads, and campaign visit, says, “Californians on Nov. 8 have a chance to stand up to the pharmaceutical industry’s greed and spark a national movement to end this price-gouging.”
Nurses have crisscrossed the state in support of Prop. 61, noting that they see patients on a regular basis who put their health at grave risk by self-rationing medication because of the high out of pocket cost.
They tell stories like this one, from a Fresno RN Amy Arlund of a “young man in his late 40s living on a fixed income, working two jobs, who was diagnosed with high blood pressure. This one medication was going to cost him over $400 a month.
‘I’m young, still in my 40s,’ he thought, ‘I’ll just have to live with it a little longer.’
About three months after this diagnosis, because he could not afford to take his blood pressure medication, he had a massive stroke and is now permanently disabled.”
Or from Long Beach RN Margie Keenan, who described “patients provided a heart stent for serious coronary disease sent home with directions to take anti-platelet drugs for continuing therapy, are returning to the ER with serious chest pain. Or dying before they get there. Why? They can’t afford the high out-of-pocket cost for their medication.”
For those not keeping track, here’s what big pharma has become, an industry with enough wealth and power to make Pablo Escobar blush:
164 – percent of price increase since 2008 for brand name drugs in the U.S.
$1.6 trillion – worldwide profits, 50 top drug companies since 1995.
$3.4 billion – federal lobbying, 1998 through 2016, more than any other industry, including the banking and fossil fuel industries.
1,400 – pharma federal lobbyists, 2015.
$11 billion – compensation for pharma executives, 2011-2015, mostly based on pay for performance (high stock prices driven by inflated prices). Ten executives made an aggregate $327 million in 2015 alone.
$1.7 trillion –pharma mergers and acquisitions spending, 1992-2015, during which drug costs, fueled by monopolization, rose by over 300 percent.
89 – percent of top 100 drug firms that spend more on marketing than on research and development (R&D), 27 percent spend 10 times as much. Much R&D is funded by taxpayers, performed at public universities.
65 – percent of industry R&D for minor tweaks to existing drugs that do little to make them more effective, but allow the company to extend the monopoly patent protection for a high priced brand name drug over a generic alternative up to 20 more years.
(Note: Find more background on the pharmaceutical industry from CNA/NNU’s Institute for Health and Socio-Economic Policy here.)
Seen enough? Prop. 61 requires the state to pay no more for medications for people it covers than is paid for the same prescription drugs by the Department of Veterans Affairs, the one agency that has authority to use public power to negotiate bulk price discounts.
Prop. 61 won’t end drug price gouging, but it’s a big start. One industry publication called California “ground zero” in the battle against big pharma and warned drug company executives, that “adoption of VA pricing by the state of California would be a “pricing disaster” for the entire U.S. drug industry.
That would be welcome. Passing Prop. 61 would send an unmistakable message that you can confront the corporate grip over our politics, our economy and our health – and win.
News of Charges in Price-Fixing Inquiry Sends Pharmaceuticals Tumbling
by Katie Thomas - NYT
The generic drug industry was jolted on Thursday as shares of many major companies tumbled after a news report said that a federal inquiry into drug price-fixing was wider than previously believed and could lead to charges by the end of the year.
Shares in Teva Pharmaceuticals, the world’s largest generic drug maker, fell more than 9 percent, and the stock of competitors like Mylan, Endo Pharmaceuticals and Impax Laboratories had similar declines.
The report, from Bloomberg, said that the investigation, being done by the Justice Department, was looking at more than a dozen companies, and that the prices of about two dozen drugs were involved.
A spokesman for the Justice Department declined to comment. Several of the companies either did not respond or declined to comment beyond statements they had previously made about the inquiry, which began about two years ago.
But investors were clearly not waiting for any additional confirmation.
In a note on Thursday, David Maris, an analyst for Wells Fargo, said the potential impact of such an investigation could shadow the industry well past next week’s election and into the new presidential administration.
“We are less concerned about the financial impact of fines, although they could be significant, but rather how items like this can bring calls for controls and oversight,” he said.
Some generic drug companies, including Teva, Mylan, Endo and Impax, have said that they received a subpoena. Mylan, for example, said that it had received a subpoena last December from the Justice Department related “to the marketing, pricing and sale of our generic doxycycline products and any communications with competitors about such products.”
A spokeswoman for Mylan said in a statement that the company is cooperating with the investigation and “to date, we know of no evidence that Mylan participated in price-fixing.”
Drug companies have come under intense scrutiny over the last two years over the prices of their drugs, particularly old drugs that have lost their patent protection but have, in some cases, jumped in price. In the case of doxycycline, an antibiotic, for example, the price went from $20 a bottle in October 2013 to $1,849 by April 2014, according to members of Congress who are investigating drug prices.
The same report found that the price of a pill of digoxin, an old heart medicine, rose to $1.10 in 2014 from 11 cents in 2012. Companies, including Impax, have said that federal investigators have asked about digoxin and other drugs.
Close to 90 percent of all drugs dispensed in the United States are for generic versions, which are generally far less expensive than name-brand drugs. A report this summer by the federal Government Accountability Office, for example, found that over all, prices of generic drugs purchased through Medicare’s Part D drug program declined 59 percent from 2010 to 2015, although some price increases were “extraordinary” during the same period.
The industry has consolidated in recent years, and Michael A. Carrier, an antitrust professor at Rutgers Law School, said that the once fiercely competitive players may no longer have as strong of an incentive to do battle. Any broad charge, Mr. Carrier said, “promises to be a bombshell.”
A study released Thursday suggests the law may be reaching a limit to its effectiveness.
WASHINGTON — President Obama’s legacy health care law has reduced the number of Americans going without health insurance to historically low levels, but continued progress threatens to stall this year, according to a new government report.
The study released Thursday by the Centers for Disease Control and Prevention suggests the law may be reaching a limit to its effectiveness in a nation politically divided over the government’s role in guaranteeing coverage.
The CDC said the number of uninsured people dipped by only 200,000 between 2015 and the first six months of this year, which it called “a nonsignificant difference.” The findings come from the National Health Interview Survey, which has queried more than 48,000 people so far this year.
Since the health care law’s big coverage expansion in 2014, millions have gained coverage each year. Now the pattern appears to be changing.
Experts say Obama’s overhaul deserves most of the credit for 20 million Americans gaining coverage since 2014. But progress has been less and less each year, and now it’s slowed to a crawl.
“It has got to be close to tapped out,” said Dan Witters, director of a major private survey that also follows insurance trends, the Gallup-Healthways Well-Being Index.
The CDC study found that during 2015, an estimated 28.6 million U.S. residents were uninsured. The corresponding number through the first six months of 2016 was 28.4 million.
The sobering numbers come as the administration seeks to whip up enthusiasm for the 2017 sign-up season, which started this week and runs through Jan. 31.
Massive change coming to state health care for poor
by Priyanka Dayal McCluskey
The federal government on Friday approved a sweeping overhaul of the state’s health care program for poor and low-income residents, pushing medical providers to better coordinate the care of nearly 2 million people.
The goals are to improve the health and quality of care for a population of patients that tends to have complex medical needs, while also attempting to control spending in the $15 billion-plus Medicaid program — the single largest expense in the state budget.
The new agreement represents the biggest change to MassHealth in two decades. It will expand the number of hospitals receiving payments for serving large numbers of MassHealth patients, from seven to 15.
The federal approval comes with a massive infusion of funds to help hospitals and other providers shift their operations to a new business model, one that gives them a set amount of money to care for patients and scores them on quality to ensure they aren’t skimping.
Marylou Sudders, the Massachusetts secretary of health and human services, said the federal funding is crucial to making the new care model work.
“If you really want to change a system, you really need to have the right investments so that system can develop the services and structure that it needs,” she said in an interview.
The state’s Medicaid program, called MassHealth, has been rooted in the old fee-for-service model of medicine, in which doctors and hospitals are paid for every service they provide. The administration plans to shift MassHealth to an emerging model called accountable care, which aims to prevent serious medical problems and costly hospital visits by providing more coordinated care that helps members stay healthy.
For the one in four Massachusetts residents on MassHealth, state officials vow that the change will mean closer communication with primary care physicians or care managers, who will help coordinate different medical, mental health, and social services.
But in the near term, the changes also could cause confusion and disruption as consumers learn about the new care models and choose their doctors.
“It’s a really important step toward a MassHealth program that protects consumers’ health in the long term, but I think the big challenge is going to be putting the program into place,” said Matt Selig, executive director of Health Law Advocates, a nonprofit group representing low-income residents. “It’s a huge undertaking — it’s uncharted territory in Massachusetts — and it’s going to be hard.”
State and national health care laws have been pushing the health care industry to move to accountable care models. The private insurance market and Medicare, the government health program for seniors, already have begun adopting such models.
Putting MassHealth on the same path is one of the most significant achievements yet by Governor Charlie Baker, a former health insurance executive. The approval of the so-called Medicaid waiver authorizes $52.4 billion in spending over five years, including $29.2 billion from the federal government.
Without changes, Baker officials say, the growing costs of MassHealth are unsustainable; spending on the program has been rising at an 8 to 12 percent clip over the past few years and is consuming an increasing share of available state funds.
It’s unclear exactly how much money the administration is hoping to save by shifting to accountable care. Other such programs across the country have produced only modest savings so far, according to studies.
The challenges are evident in Massachusetts. A similar but smaller effort to better manage care for a group of poor and disabled residents has proved more complicated than expected, resulting in severe financial losses.
“This kind of reform takes time,” Sudders said.
The state was under a deadline to come up with a new MassHealth plan, as $1 billion in federal funding was scheduled to expire on June 30, 2017.
The new deal includes $4.8 billion in funding for hospitals that serve especially large numbers of MassHealth patients. There is also $1.8 billion in new grants to help health care providers shift to new accountable care models. Some of the money is contingent on Massachusetts meeting certain performance benchmarks set by federal officials.
In some cases, the deal may allow patients to receive additional services that are hard to access under the current system. In response to the ongoing opioid crisis, for example, MassHealth will expand residential rehab treatment for people with a substance abuse disorder, said Daniel Tsai, assistant secretary of MassHealth.
Currently, the program covers shorter-term detox treatment, but not longer-term residential programs.
Massachusetts is one of several states moving to adopt accountable care models for its poor and low-income population, following similar moves by Rhode Island and Vermont, according to federal officials.
“This is a very big deal,” said John E. McDonough, a professor at Harvard T. H. Chan School of Public Health. “This puts MassHealth on a transformation path from where it is today.”
Advocates said the planned changes could help improve care for patients by boosting communication and coordination among different entities — primary care doctors, hospitals, therapists, social service agencies — that serve the same person.
“All these different types of services that you used to get from a wide variety of organizations, it’s going to be in their interest . . . to make it much more coordinated and easier for you to access,” said Audrey Shelto, president of the Blue Cross Blue Shield of Massachusetts Foundation, a research and advocacy group. “They’re going to be held very accountable for making sure you have access to all those services.”
Many details of the new MassHealth plan have yet to be worked out. Six organizations that may include some of the state’s major medical providers are set to begin accountable care pilot programs as early as next month. Officials have not identified the organizations yet.
The new federal funding kicks in next July, and full implementation of the new care model is set to begin in December 2017.
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