Report: In Mass. Health Care, System Skewed So Rich Get Richer

A report released today by the Healthcare Equality and Affordability League (H.E.A.L.) — a partnership between the for-profit Steward Health Care System and the union, 1199 SEIU United Healthcare Workers East — finds that disparities in hospital costs and financing across the state are driving “a vicious cycle” of inequality in health care.

The result, according to this analysis, is that medical care is becoming less affordable for lower-and middle-income families in Massachusetts, and the disparities in hospital financing are “compromising the viability of community hospitals.”

The group is calling for new, and what they call more “fair” reimbursement rates so that poorer, community hospitals (with a greater proportion of Medicare and Medicaid patients compared to the higher-cost Boston teaching hospitals) can continue to serve the lower-income patients, among other financial recommendations.

David Williams, president of the Boston consulting firm Health Business Group, who was paid by H.E.A.L to research and co-author the report, says: “What hasn’t been demonstrated before is what impact these financing disparities have on communities and community hospitals.”

He notes: “The hospitals that have the highest percentage of publicly funded patients, they get paid less, but in addition to that, those hospitals also get the lowest commercial rates — because they’re not in as strong a position to negotiate — so that means that they’re doubly disadvantaged…it means that the hospitals serving middle-class and lower income communities don’t have the resources to compete effectively with those hospitals that get higher reimbursements.”

Clearly, the group’s recommendations would benefit the Steward-owned hospitals, Williams acknowledges, but, he adds: “it would also help with the state’s overall approach to cost containment.

I asked Nancy Turnbull, an associate dean at the Harvard School of Public Health, to take a look at the report and here’s what she had to say:

…This report looks to be raising critical issues regarding payment disparities. We’ve known for years, from the work of the [Attorney General], [Center for Health Information and Analysis] and others that these disparities exist and are, in many cases, getting worse. So far, we’ve done little to address them, and the effect these disparities have on lower paid providers and the patients for whom they care. However, I don’t think the solution is, in most cases, to just increase the rates of payment for poorly paid providers, although that is a needed action for some. We also need to talk about reallocation of existing payments, and about costs. I am supportive, to some extent, of giving consumers reasonable financial incentives, based on their income, to use lower cost providers—although lower paid is not the same as lower cost–but we also need approaches that are systemic. Consumers in tiered and high deductible health plans aren’t going to solve this problem without tough action by state government and other payers, including, in my opinion some regulation of rates of payment. And most tiered networks available so far are regressive — they impose higher costs on lower-and moderate-income people. They address one form of inequality by creating another.

Among the findings, according to the H.E.A.L press release:

“The rich get richer as highest cost hospitals attract a greater proportion of patients with commercial insurance, which have higher reimbursement rates than Medicare and Medicaid.”

(H.E.A.L report)

(H.E.A.L report)

–“Patient migration for routine care from community hospitals to high cost Boston teaching hospitals increases total medical costs and contributes to higher premiums for all individuals and families with commercial insurance (non-Medicare nor Medicaid). Additionally, low-income patients, forced to travel greater distances to receive routine care are more likely to forgo treatment until conditions become acute and require more expensive interventions.”  Continue reading

New Home Birth Data: Numbers Rise A Bit, Controversy Remains Unchanged

A new CDC analysis of trends in out-of-hospital births from 1990-2012 found that home births are on the rise — but only a tiny bit.

The federal agency reports that 1.36 percent of U.S. births occurred outside a hospital in 2012, up
from 1.26 percent in 2011. Those new numbers mark the highest level of non-hospital births since 1975, according to the CDC.

In terms of actual births, that means 53,635 births in the U.S. took place out of a hospital in 2012, including 35,184 home births and 15,577 birthing center births, the CDC says.

(Source: CDC)

(Source: CDC)

Here are some more findings from the CDC news release:

• In 2012, 1 in 49 births to non-Hispanic white women were out-of-hospital births;

•The percentage of out-of-hospital births was generally higher in the northwestern United States and lower in the southeastern United States;

•Out-of-hospital births generally had a lower risk profile than hospital births.

Continue reading

Responding To Relman: ‘Spaulding Gave Charlie His Recovery’

Yesterday we linked to Dr. Arnold Relman’s gripping near-death story of breaking his neck last summer, and the medical odyssey that followed. In it, Relman, the former editor of The New England Journal of Medicine, lavished superlatively high praise on Massachusetts General Hospital, where he was initially treated, but was much more critical of Spaulding Rehabilitation Hospital in Cambridge, where he spent about a month recovering.

That critique left some Spaulding patients (and their families) feeling perplexed and a bit slighted. Jeanette Atkinson, the wife of former Spaulding patient Charlie Atkinson, asked for space to offer another perspective.

Charlie Atkinson, 78, at home, is still recovering from West Nile Virus. (Courtesy)

Charlie Atkinson, 78, at home, is still recovering from West Nile Virus. (Courtesy)

Charlie was the subject of a recent CommonHealth post: West Nile Story: 400 Days In Hospital, A New View Of Health Care (And Life)

Jeanette submitted this “rebuttal” after reading Relman’s piece:

My husband, Charlie Atkinson, and I are in a particularly good position to respond to Dr. Arnold Relman’s article, “On Breaking One’s Neck,” since Charlie recently spent five weeks at Massachusetts General Hospital and thirteen months at Spaulding Long Term Acute Care Hospital in Cambridge and received spectacular care at both.

MGH saved his life. As Charlie (age 76 at the time) fell into a deep coma in August, 2012, doctors there inserted a breathing tube, started a ventilator, administered oxygen and drugs, inserted catheters, ordered tests, and worked around the clock to diagnosis his illness – which turned out to be West Nile virus of the most devastating kind.

After three weeks in Mass General’s intensive care unit and two in the respiratory acute care unit, he was stable enough to be discharged – but to where? He was tethered to respiratory machinery; he was almost completely paralyzed; he knew his name, but not where he was; and he would never have been able to maintain the rigorous physical therapy schedule at a place such as Spaulding Rehabilitation in Boston. He was still far too sick to be admitted to a regular nursing home/rehabilitation facility.

Spaulding Hospital, Cambridge, gave him his recovery. We’d never even known of the existence of “LTAC’s,” or Long Term Acute Care hospitals. Their range of services is much more limited (and far less expensive) than those of full service hospitals such as MGH, and much more focused on helping patients achieve a maximum quality of life while treating their on-going medical problems. Spaulding, Cambridge does that superbly. Continue reading

Mass. Launches A Grand Experiment: Pricing Health Care

There’s a grand experiment underway in Massachusetts and we are all, in theory, part of it.

Here’s the question: Can we actually list prices for childbirth, MRIs, stress tests and other medical procedures, and will patients, armed with health care prices, begin to shop around for where (and when) they “buy” care?

One of the first steps in this experiment is a new requirement that hospitals and doctors tell patients who ask how much things cost. It took effect Jan. 1 as part of the state’s health care cost control law and we set out to run a test.

Our sample shopper is Caroline Collins, a 32-year-old pregnant real estate agent from Fitchburg who is trying to find out the price of a vaginal delivery. Her first call is to the main number at Health Alliance Hospital in Leominster. From there, she is transferred to the hospital’s obstetrics department. A receptionist there tells Collins to call the billing office at UMass Memorial Medical Center in Worcester, Continue reading

West Nile Story: 400 Days In Hospital, A New View Of Health Care (And Life)

By Dr. Annie Brewster
Guest contributor

In August of 2012, Charlie Atkinson was bitten by a mosquito in the garden outside his home in Cambridge, Mass.

Charlie Atkinson, 78, at home, is still recovering from West Nile Virus. (Courtesy)

Charlie Atkinson, 78, at home, is still recovering from West Nile Virus. (Courtesy)

From that bite, against the odds, he contracted West Nile Virus. It nearly killed him.

Charlie was in a coma for more than a week, paralyzed in his left arm and right leg. He spent more than 400 days total in two hospitals. He is still recovering.

Before the fateful insect bite, Charlie, married, with four children and nine grandchildren, was incredibly active. He was an avid tennis player, a self-taught pianist, an educator and entrepreneur who started numerous companies. West Nile Virus changed that life.

I met Charlie, now 78, on a snowy December day at his home, now retrofitted with a wheelchair ramp and a stair lift. We spoke in the sunny dining room, which has been transformed into a bedroom, complete with a hospital bed and Charlie’s ventilator equipment (he has a tracheostomy and is on the ventilator at night). Charlie lay propped up on his pillows as we spoke, and his warm handshake and bright eyes made me feel right at home.

A self-described “Just Do It” guy, Charlie fought his way back from near death with amazing determination. He surpassed the predictions of the medical community and has continued to make progress: he can now get around with a roller walker and even take steps on his own with a cane.

But beyond his physical comeback, Charlie’s story is also about learning to be a smarter patient; questioning the conventional medical wisdom and seeking out health care providers who are truly compassionate.

Listen to Charlie here: 

West Nile Virus is an arthropod-borne virus (an arbovirus), most often spread by mosquitoes between the months of June and September. It has been found in 48 states (all but Hawaii and Alaska) and in the District of Columbia. It was first detected in North America in 1999 and has continued to spread since that time. In 2013, the CDC reported 2,374 cases and 114 deaths. Continue reading

Partners On Anti-Merger Report: ‘Misleading,’ ‘Flawed,’ ‘Inaccurate’


Partners HealthCare does not hold back in the response it plans to file today with the state’s Health Policy Commission (HPC). The commission issued a report last month that marked a rare effort to crimp Partners’ dominance in the Massachusetts market. The commission said that if Partners adds South Shore Hospital in Weymouth to its growing network, costs will increase around $23-26 million a year.

Wrong, says Partners, in an 89-page rebuttal that includes dozens of letters and testimonials from South Shore area leaders who support the merger. The commission should withdraw its finding, concludes Partners, and not send the proposed merger to the state attorney general for further regulatory review.

Some key points from Partners’ response:

1) The merger would not “add $23-26 million in annual physician health care costs.”

Partners says the HPC doesn’t understand how Partners’ physician contracts work. The assertion that the merger “will result in significant annual physician cost increases is based on material misunderstandings of both the Partners payer contracts and the process and goals of the parties’ proposed physician development efforts” in the South Shore Hospital area.

2) If there are any cost increases, they would be “offset” by better value and more efficient care.
Continue reading

Comparing Quality In Childbirth: Key Questions For Doctors And Hospitals

I’ve heard from a lot of moms this week about our new online tool for Comparing Childbirth in Massachusetts. It offers a side-by-side review of hospitals using five quality measures.

photo: Matha Bebinger

photo: Matha Bebinger

OK, these mothers say, quality measures are important, but I don’t want to make a decision based on stats alone.

So here’s a way to translate these measures (which experts say are good ways to assess quality) into an action plan. It’s a list of questions you can use when choosing the doctor or midwife who will help deliver your baby. Please add your own below!

Question: What is your C-section rate?
Background: Many childbirth experts say 15 percent is a good target rate. If the rate for your doctor or the hospital where he or she works is higher, have a conversation about why.

Question: When you are called to the labor floor, do you still have responsibilities in the office?
Background: Some hospitals have or are moving to scheduled hours for OBs in Labor and Delivery units. But in many places an OB is pulled between office hours, labor and sometimes surgery as well. Some childbirth experts say these time pressures push doctors to opt for more C-sections that are medically necessary.

Question: What is your practice regarding elective inductions? Do you induce women before 39 weeks if everything is going well? How long do you suggest women wait, past their due date, to be induced?
Background: Many childbirth experts say babies should not be delivered before 39 weeks to avoid complications, and because babies need the last two weeks for brain, lung, and other vital organ development. Some hospitals wait until two weeks after a mom’s due date to induce because waiting for labor to begin naturally can help women avoid a C-section. But inductions are needed in cases where the mom or baby are in distress.

Question: Once you find a doctor you like, if he or she is part of a larger practice, ask…Do all the doctors in your practice share the same philosophy about: inductions, epidurals, when to declare a mom is no longer making progress in labor? Continue reading

Moms Speak Out: On Improving Childbirth In Boston-Area Hospitals

When we opened up the “lines” for an online chat about quality and childbirth, moms dove in with comments and questions about induction, malpractice and worse results for black women as compared to whites.

We had help answering questions from:
Gene Declercq, a Boston University School of Public Health professor who has studied childbirth practices for more than 20 years.
Dr Jeff Ecker, an OB/GYN at Massachusetts General Hospital and a member of the Massachusetts Perinatal Quality Collaborative Advisory Committee.
Betsy Deitte, a mom from Needham who had her third child, a boy, in September.
And Rebecca Loveys of Watertown, who delivered her second son in August.


First question, from Agnes…
Is there a way we can improve these measures of childbirth by focusing not just on the labor-and-delivery part, whose benchmarks mostly are set by hospital birth, but on childbearing? On a woman’s experience of her pregnancy and not just the outcome?

Dr. Jeff Ecker responds…
I think it would be difficult to do so, as they are such different experiences. A woman can have a perfectly healthy pregnancy, and have a difficult delivery. One does not necessarily affect the other experience.

I agree that it would be ideal to focus on the whole experience of pregnancy, childbirth and post-delivery care. We have, to date, focused mostly on the process of labor and delivery because that is the point at which we most reliably collect data (think: birth certificate). Increasingly we are turning to evaluate patient satisfaction. But I need to tell you that in my experience, much of satisfaction is driven by outcome.

Question from Katie…
To what extent does the fear of medical malpractice dictate a woman’s birth experience?

Gene Declercq responds…
The research on the effects of fear of malpractice on obstetrician’s behavior is somewhat mixed. In terms of whether things like malpractice premiums are directly related to, say cesarean rates, there is not much support for that link. However, in terms of perception of malpractice concerns on obstetrician attitudes it continues to have an impact since the widespread feeling exists that interventions like cesareans are more easily defensible in court.

Cara responds…
As a labor and delivery RN I know that the fear of lawsuit is a huge driving force in the care we provide. I can’t tell you how often I hear docs and midwives say “Well I really should do (insert intervention) because how would it ‘look’ if we didn’t”…..”look” being the operative word and it means when the lawyers review the chart if a lawsuit did happen.

Ecker responds…
Cara, you’re right. Those on labor and delivery spend much time (too much time) talking about lawyers and how they might spin our care. But research is split about how such concerns actually affect care and outcomes. It turns out to be difficult, for example, to demonstrate that a recent malpractice settlement drives care in any particular direction. Don’t get me wrong: I’m no fan of lawyers second guessing good care after the fact but they’re not the only things driving cesarean rates up.

Question from Sarah…
How do doctors decide when during a woman’s labor to recommend a Cesarean section? Do most doctors have their own formula or threshold for deciding when the woman is not making progress that will lead to a vaginal delivery?

Dr. Ecker responds…
There’s no one formula for determining when progress isn’t being made and cesarean delivery is best recommended. Continue reading

Nonprofit? Really? Big Salaries For Chiefs At Mass. Charitable Hospitals, Health Plans

A sample chart from the Attorney General's report showing compensation details for the top paid hospital executive in 2011, John O'Brien.

A sample chart from the Attorney General’s report showing compensation details for the top paid hospital executive in 2011, John O’Brien.

Compensation for CEOs of the top 25 nonprofits in the state, including hospitals and health plans, ranged from more than $487,000 to approximately $8.8 million, according to a new report released today by Attorney General Martha Coakley.

“Massachusetts is unique,” Coakley says, “in that many of our largest employers are non-for-profit institutions.”

These hospitals, health plans (and universities included in Coakley’s report) “must compete with national for-profit companies for CEO talent while staying true to their charitable mission.”

So do these CEO salaries achieve that balance?

Coakley suggests these organizations could be more balanced by paying more attention to the difference between executive and non-executive pay and by considering “the level of public support the organization enjoys in the form of exemption from property tax, corporate excise tax, sales tax and other forms of taxation.”

The numbers below, from 2011, look big and they are, just keep in mind they include retirement, bonuses and all other compensation.


1) John O’Brien at UMass Memorial Health Care $2,350,992.00 (retired earlier this year)

2) Gary Gottlieb at Partners HealthCare $2,163,199.00

3) Betsy Nabel at Brigham and Women’s Hospital $1,939,479.00

4) Peter Slavin at Massachusetts General Hospital $1,758,691.00

5) Mark Tolosky at Baystate Health $1,636,004.00

6) James Mandell at Children’s Hospital $1,503,885.00

7) Linda Shyavitz at Sturdy Memorial Hospital $1,496, 532.00

8) Edward Benz at Dana-Farber Cancer Institute $1,406, 432.00

9) Kate Walsh at Boston Medical Center $1,378,292.00

10) Howard Grant at Lahey Health $1,045,479.00

11) Dianne Anderson at Lawrence General Hospital $674,042.00

12) Kevin Tabb at Beth Israel Deaconess Medical Center $360,877.00 (partial year)


1) Jim Roosevelt at Tufts Health Plan $2,116,683.00

2) Eric Schultz at Harvard Pilgrim Health Plan $1,460,982.00

3) Andrew Dreyfus at Blue Cross Blue Shield $ 1,111,075.00 (Dreyfus declined some compensation) Continue reading

Under Pressure To Control Costs, Partners And South Shore Forge Ahead

“Nothing we have seen or heard changes our minds about the value that this proposal offers to patients in southeastern Massachusetts. Our combined vision with South Shore Hospital will improve the care that patients receive and will lower health care costs.”

– Rich Copp, spokesman, Partners HealthCare

This is Partners’ response after the Massachusetts Health Policy Commission (HPC) approved a report yesterday that says if Partners merges with South Shore Hospital, the cost of care through those facilities and their related physicians would increase $23-$26 million a year. Both the report’s author and several doctors I spoke to from South Shore say this is a conservative estimate, that cost increases would likely be substantially higher.

The commission does not have the authority to scuttle the merger, but this report is the first time a public body has analyzed the financial impact another Partners merger could have on the state’s attempt to hold down health care spending. Partners, the report says, already has total net assets that are “more than three times the combined assets of the next three largest systems in Massachusetts.” This is about pressure. So what does the board want?

Commission board member Paul Hattis said for Partners to serve its mission of increasing value to maintaining excellence, then “the best way forward is to abandon these proposed transactions.” This merger, said Hattis, would have “frightening implications for increasing total health spending for employers and individuals, particularly in southeastern Massachusetts.”

HPC Chairman Stuart Altman stopped short of asking Partners to scrap the deal, “but they should think hard about changing the structure of the linkage.” Partners could, Altman suggests, pull South Shore Hospital into its network but keep an affiliated physician group, Harbor Medical Associates, separate. Moving Harbor and some other South Shore doctors up to Partners physician reimbursement rates alone would increase costs almost $16 million a year after four years.


Or, says Altman, Partners “could make a commitment that they would not see any increase in total medical expense and if they did they would give the money to expand mental health services or care for the poor.” The bottom line, says Altman, is that “if you’re going to depend on a functioning competitive marketplace, you really need a functioning competitive marketplace.” Continue reading