Does Your State Help or Hinder Your Access to Quality Health Care?
This article reviews state health care laws impacting clinical care and
resourcing in light of the Accountable Care Act and the needs for primary
health care. The recent articles in the academic Health Affairs Journal and by
the nonprofit advocacy group, The Commonwealth Fund, address the issue of
market competition in health care delivery and the impact on services as well
as the potential for anti-trust issues. Anti-trust occurs when a single health
care entity or a consortium of providers exerts enough control of the market in
a given geographic region, to dictate prices, and to be able to perform in an
atmosphere where the consumers have fewer choices. In other words, to charge
more without offering an improvement in service. Now, with that in mind, some
of the state laws that throw a monkey wrench into this idea of a competitive
marketplace for health care are; certificate of need requirements, any-willing-provider
regulations, and scope of practice limitations. One example of a legislative
limitation on the regulation of health care services, as reported in the
state-wide surveys in Unraveling U.S. Health Care-A Personal Guide[1],
several states outlaw the practice of naturopathy, which limits the number of
clinicians for primary health care. There are also administrative limitations
which states use to restrict access for clinical training, such as limiting the
funding to university programs for nurse practitioners, thereby restricting the
number of clinicians available in the health care system. From an economic
standpoint this keeps the compensation high for the practitioners, but results
in a dearth of clinicians in an area of great societal need.
As Martin Gaynor points out in Health Affairs’ May 2, 2014 publication,
Competition Policy, and Markets: Navigating the Enforcement and Policy Maze,
health care delivery, inclusive of insurance and health care services is
governed by many different and oft times conflicting entities, from federal to
state and local governments.[2]
This mishmash of regulation does not result in more effective or less expensive
health care.
The Patient Protection and Affordable Care Act created the Accountable
Care Act mandates for health care organizations, which pays for clinical
performance for treatment of targeted diseases. Now that the ACA has been
implemented by many health care systems, financial rewards have been paid, and
two years of data is available, there has been sufficient time for states to
evaluate and modify their health care sector regulations. One of the consequences of the ACA has been
the merger of many hospitals, which has reduced competition and services in
some areas. In Washington State, as I have previously written, Providence
Health Care acquired Swedish Hospital Group and Peace Health controls many of
the markets in smaller cities throughout the state. Though consolidation may
benefit these health care behemoths, it does not necessarily improve or reduce
the cost of health care for the consumer.
In order to have an effective market place, one must have a willing
buyer and a willing seller, in pure economic terms. Health care, because it is
so heavily regulated is not a typical consumer good, however, because most of
the health care systems in the United States are not government owned, we do
essentially have a privatized system of health care delivery, albeit one which
is heavily subsidized by government payments.
These states have enacted price transparency laws for health care
providers to bolster their consumer marketplace in light of the Accountable
Care Act provisions: Arizona, Arkansas, California, Colorado, Delaware,
Florida, Illinois, Indiana, Kentucky, Maine, Massachusetts, Minnesota,
Missouri, Nevada, New Hampshire, North Carolina, Ohio, Oregon, Pennsylvania,
Rhode Island, South Dakota, Texas, Utah, Virginia, Vermont, Washington, and
Wisconsin.
Though price transparency is one of the key aspects of an effective
consumer market place from which to buy goods and services, it is not optimal
unless you also have the quality of the services also disclosed. Medicare has
tracked health care outcomes for years and there is information available by
procedure for price and quality on its web site. In January 2014, I presented a
consumer tutorial on this tool in my Phinney Community Center presentation. It
was obvious from that presentation, that consumers still find the availability
of health care quality information difficult to understand and access. If we
are going to persist in offering a private sector market place for the purchase
of health services, we must demand that price and quality information be available.
Clinical outcomes, such as hospital readmission rates, infections, and surgical
errors, are examples of health care quality measures. Though aggregated
information is available on this data, few states have taken the time to match
patient outcomes with pricing. As detailed in chapter seven, Patient Safety-Who
Reports Medical Errors, in my 2013 book, Unraveling U.S. Health Care-A Personal
Guide[3],
Minnesota has a state web site that allows anyone to view each hospital’s
medical errors in the state.
As revealed in the National Conference of State Legislatures’ April
2014 article, Transparency and
Disclosure of Health Costs and Provider Payments: State Actions, Minnesota is
also the state which has created a commission to link health care quality and pricing
information in a consumer friendly model, to enhance the effectiveness of its
health care market place.[4]
This level of transparency is the gold standard and is something consumer
driven health care advocates should demand.
Nevada also has an interesting law which mandates health care providers
must charge everyone the same price for the same service, in other words they
can’t charge higher prices to the uninsured or for those on different health
plans. This too, is an interesting approach to a market place correction,
because if all prices for the services are set and transparent, then the health
care providers must compete on quality, which is really, the most important
aspect of health care. It will be interesting
to see how this plays out in Nevada.
And of course, Maryland has had a mandate for level pricing for
hospital services on the books for thirty years, and it has been effective in
keeping health care costs down, as reported in my December 2013 article on
hospital price transparency.
Stay tuned for more information on initiatives to improve consumer
information on health care quality and price thus enabling individuals to make
informed health care decisions. And this is the healthpolicymaven signing off,
encouraging you to share this article with anyone who may benefit.
[1] http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972
[2] http://content.healthaffairs.org/content/early/2014/05/13/hlthaff.2013.0810
[3] http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972
[4] http://www.ncsl.org/research/health/transparency-and-disclosure-health-costs.aspx#Legislation
