While the fate and integrity of the Patient Protection and Affordable Care Act (PPACA) are likely to be clarified in this highly polarized presidential-election year, Massachusetts continues along a path (begun 5.5 years ago) to reform its health-care system under a law that shares many of the hallmarks of the PPACA—including the controversial individual mandate to buy insurance currently before the Supreme Court.
Jonathan Kruskal, MD, PhD, chair of radiology at Beth Israel Deaconess Medical Center (BIDMC), Boston, provided a guided tour through that journey on December 28, 2011, at the annual meeting of the RSNA in Chicago, Illinois. His riveting presentation, “Health Care Reform: What Does It Mean for Radiology,” paid particular attention to the effects of reform on radiology.
Kruskal notes that the health-care crisis is coming down to two monumental issues: providing access to high-quality care and controlling costs. “We, in Boston, will be fortunate to have had seven years of experience already when the PPACA comes into effect in 2014,” he says. “We are very much in it right now, experiencing it on a daily basis.”
Since the state’s reform law was enacted in 2006, it has widened access to care, but cost continues to be an issue, with Massachusetts and Vermont leading the nation in the average monthly cost of individual health insurance, in 2010, at double the national average (at $400 per person).¹
Another issue that received considerable media coverage in 2010—and attracted the attention of government officials—was the wide price differential among hospitals in Massachusetts. “Within Boston alone, there is sometimes a threefold price difference for every type of service, including imaging services,” Kruskal acknowledges. The law established an independent public authority, popularly known as Health Connector (see figure), to act as an insurance broker that offers private plans to residents through a Web service that enables residents to do comparison shopping for individual health-insurance policies and specific medical services.
Kruskal reports that costs for gall-bladder removal at various Boston-area hospitals range from $7,000 at Quincy Medical Center to $12,500 at Massachusetts General Hospital. The same comparison can be made for MRI, CT, or any other service. For patients attempting to reduce their copayments and deductibles, he notes, “It’s all there on the Web to help you make your decision to reduce your health-care cost.”
A Race to the Bottom
In June 2010, Martha Coakley, Massachusetts attorney general, issued a report 2, that found that spending for private health insurance in Massachusetts had climbed 6% from 2007 to 2008 and 10% from 2008 to 2010, significantly outpacing the national averages of 4.9% and 4.6%, respectively.
“Not only were the premiums the highest in the nation,” Kruskal recalls, “but health-care costs were outpacing the nation’s. In fact, per-person health spending in Massachusetts was 15% above the national average.”
The report also contained some sobering data on imaging services covered under MassHealth (Medicaid): Nationally, spending on diagnostic imaging for the privately insured grew at an average rate of 10% annually from 2007 to 2009 (when spending reached $1.3 billion); Medicare-covered spending increased 2% from 2007 to 2008 (reaching $451 million); but MassHealth-covered spending on diagnostic imaging increased 27% from 2007 to 2008 (reaching $113 million).
“These are huge numbers, and they certainly have grabbed the attention of politicians,” Kruskal notes. “They are absolutely determined to reduce the cost of imaging services.”
Just weeks prior to the 2011 RSNA meeting, Coakley outlined a three-pillared plan 3 to help contain the state’s health-care costs. First, providers of health-care services would be required to disclose the full amount that consumers could be liable to pay. “If you are going to give a CT scan, there, on the wall, it must show you how much it’s going to cost,” Kruskal says.
Second, when a provider reaches a certain level of market clout, it would trigger a market review. Third, if the market has not corrected unwarranted price variation by 2015, the administration would be able to reject contracts with too much or too little price variation. In response, health journalist Philip Betbeze writes, “The future of health care looks increasingly like a race to the bottom on pricing.” 4
Kruskal explains, “This is what we, as an imaging