Managed Care - May 2008 - (Page 49) tunity to finally control health care costs. “What is the number one reason for a decrease in physicians going into primary care practice? Money. They get paid way less then specialists.” Budget There are two possible approaches to this problem, Kingsdale says. The system can throw “ad hoc money” at PCPs: free housing, or subsidies to help repay medical school loans. Or “If you had a budget and you had to figure out how you make these dollars stretch, the solution would be to pay the specialist a little bit less, because that would make going into specialty less attractive, and pay the PCP a little bit more,” says Kingsdale. He bristles at the suggestion that this smacks of wage and price control. “I’m saying work within a budget, you know, $5,000 per adult per year,” says Kingsdale. “This is just the way HMOs work. Use nurse practitioners for the 20 percent of primary care for which internists and FPs are overtrained. Did they really do seven years of post-graduate training to give flu shots, treat sore throats, and explain the value of exercise? A budget forces you to make trade-offs and to find lower-cost ways of getting the job done.” Proponents say that the financial turbulence rocking RomneyCare reflects just how successful the program’s been in signing up the uninsured. “Our costs per person are actually below budget, not above,” says Kingsdale. “We’re just helping many more people than we had anticipated at this point. That’s a good problem.” Right now, officials seem to be looking at some fairly low-hanging fruit as a possible financial rescue. “If we have to tax tobacco, we will,” says Kingsdale. Indeed, legislators are looking to hike the tax on cigarettes by $1 a pack, hoping to raise $175 million to shore up RomneyCare and to dissuade cash-strapped youngsters from smoking. Of course, this is problematic. A $1-a-pack tax in Iowa drove cigarette sales down by 36 percent. Success like that could conceivably kill the golden goose. Another revenue-raising method has to do with the $295 per employee, per year that some companies have to pay to make what the state calls a “fair share contribution” to the program. In general, companies that do not provide health coverage, or enough of it, must ante up. If you think that $295 per employee, per year doesn’t seem like a whole lot, you get the point. There’s talk that the amount will be increased. Still, both methods face obstacles. They may be vulnerable to the “tax and spend” charge that has launched many a political career. Other possible solutions might be hard to pull off. For instance, Magee, of the Massachusetts Medical Society, talks about inducing doctors to think about cost. “We can’t do it at the $100 million level; we have to do it at the one-test or one-prescription level. In a system where the cost of health care is as important as it is right now, physicians are insulated from it more than anyone else in society.” Kingsdale returns to budgeting. “Now, so much of the ingenuity and the entrepreneurial and competitive urge in medicine is focused on increasing revenues. If we have the framework of a budget, even if the budget is increasing year to year at an affordable rate, we can turn some of that into ‘How do you do the most good for people within a limited budget?’” Magee doesn’t necessarily believe that the financial situation is as dire as some of the news media make it out to be. “If you say that they’re anticipating $100 million in the red next year, that’s more than you and I will ever see. But if you look at it in the totality of things, we’re talking about roughly 3 percent of the cost of health care. That doesn’t sound quite so onerous.” It’s certainly worth what good RomneyCare has done, Kingsdale says. “We are perhaps the only state in the country that is confronting the question, ‘How do we make close-to-universal health insurance affordable?’ That’s a healthy debate.” MC For further reading “No Miracle in Massachusetts: Why Governor Romney’s Health Care Reform Won’t Work,” June 6, 2006, Cato Institute. Available at http://www.cato.org/ “Commonwealth Connector Employer Handbook,” Nov. 1, 2007, Commonwealth Health Insurance Connector Authority. Available at http://www.mahealthconnector.org/ “Health Connector Facts and Figures,” March 2008, Commonwealth Health Insurance Connector Authority. Available at http://www.mahealthconnector.org/ “An Act To Promote Cost Containment, Transparency and Efficiency In The Delivery of Quality Health Care,” 2008. Massachusetts State Senate Bill 2526. Available at http://www.mass.gov/legis/bills/ senate/185/st02/st02526.htm MAY 2008 / MANAGED CARE 49 http://www.cato.org/ http://www.mahealthconnector.org/ http://www.mahealthconnector.org/ http://www.mass.gov/legis/bills/senate/185/st02/st02526.htm http://www.mass.gov/legis/bills/senate/185/st02/st02526.htm
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