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to help spur discussion?

Will players release data
to help spur discussion?

In the community discussion to be held Wednesday by the Rochester Health Commission, there are a number of baseline facts that would help focus the inquiry. Some data are publicly available, but getting the facts about other issues will require the cooperation of various players in our health care system. Their willingness to provide such information and to commit to meaningful next steps based on it will be a test of whether we can continue to provide a true community health care system and have a meaningful discussion of the strengths and weaknesses of our financing and delivery system.
Let us start with Eastman Kodak Co., since its recent decision to make a self-insured plan its base health benefit in Rochester brought the role of community rating back on the local agenda. We have heard from Kodak that its costs for health benefits outside Rochester have been declining while they have continued to increase in Rochester. What does this mean? How much have they declined elsewhere, increased here, and what are the actual costs per employee here and elsewhere? Relative changes in cost between Rochester and elsewhere are not unimportant, but evaluating their significance depends on knowing those other facts.
What has been the increase in marketing costs for our hospital systems (ViaHealth, Strong Partners Health System Inc. and Unity Health System), their affiliated hospitals and employed physicians, and for our insurers in all their product lines? Likewise, what has been the increase in marketing costs for the two individual practice associations and their affiliated networks that are gearing up to provide direct contract services (Doctors’ Health Plan and Crossbridge Physicians P.C.)? Let us compare those costs in say 1993 or 1994, when we were still touting ourselves as having a model health care system, with those of 1997 annualized from the first nine months of this year.
Based on the number of advertisements I see in the press, on television and on billboards, I have little doubt that a lot more is being spent on advertising, but the real question is how much more. Is it enough to care about given the overall cost of the system, or is it a meaningful example of increased costs with no attendant increase in value?
How do our costs really stack up against those elsewhere in the country? There are annual surveys conducted by national consulting firms which measure costs of both indemnity insurance and health maintenance organizations. Our insurers and employee-benefit managers know or have access to this data. How about the rest of us? What about looking at Medicare data since that is based on a uniform national program? The recently enacted Balanced Budget Act of 1997 made significant changes in reimbursement for Medicare HMOs, with low-cost regions standing to gain substantially. Are we a big winner in this program?
There has been recent public speculation about the cause of our relatively low uninsured rate. Is it due to community rating and the lack of multiple health plans that reduces the opportunity to “cherry pick” the good risks and shun the bad? Or is it due to a stronger-than-average manufacturing sector in which decent health benefits are the norm even in smaller companies? Since the last study of this was 10 years ago and has been questioned by the consultant who investigated the issue, why don’t we conduct a serious study to try to figure this out? Does anyone care enough about this to pay for such a study, or shall we just talk some more?
Let us not forget the patients and primary-care providers in all of this. The same day that the community forum was announced in the local paper, the New York Times Magazine featured an article about managed care in the Boston area. I was struck by the descriptions of how patients had to change doctors because their employer had changed health plans, and how each plan had different drug formularies and other benefits rules. Has there been any serious discussion about the value of a system in which patients do not have to switch providers and lose continuity of care because of employer health plan changes?
We focus a lot on employers and insurers, but we should not let our physicians and hospitals off the hook if they are not being as efficient as their peers elsewhere. A few years ago, if you compared hospital discharges in this area to the rest of the state, we were significantly above the norm for certain eye procedures. To the extent that this is still true, or if there are similar significant deviations, we should stop just viewing such information as interesting and seriously inquire why there are significant outliers and what to do about them.
For years it has been an article of faith that hospitals in New York State have longer lengths of stay than elsewhere because, well, they are in New York State. When Medicare reimbursement changed in the mid-1980s so that hospitals got paid the same amount for a particular diagnosis whether the patient stayed a longer or shorter time, lengths of stay elsewhere dropped, as basic economics would suggest they should. Not in New York. Recently our hospitals have seen their average length of stay and overall occupancy plummet. How far from national norms are we now? Is the local drop in occupancy solely due to getting patients awaiting nursing-home placement out of the hospital more quickly, and to the extent it is due to something else, what has facilitated that change?
Some of these questions are relatively easy to answer. The data is there, if only those who have it will give it up to the community. The questions concerning various costs and cost comparisons at the start of this article fit this category. Questions about how much we utilize certain procedures or interventions, or about the length of hospital stays, have been studied both locally and nationally for decades. Some of those questions were asked in the Health Futures for Rochester study almost a decade ago, but never fully answered.
For both categories we need a serious commitment to truth telling. If something is thought to be way off the norm in the wrong direction, the critics of our system should say so and back up their position with data. If they cannot factually support their assertions, they should keep quiet. Likewise, those who say we are doing well in a particular area should support their position with data to prove it, or hold their peace. If we are off the norm and cannot explain why, there should be a public commitment to hold those who could change things to do so, without having to wait a decade for a response.
(Rene Reixach is an attorney with Woods, Oviatt, Gilman, Sturman & Clarke LLP, where he concentrates his practice in health law. He formerly was executive director of the Finger Lakes Health Systems Agency.)

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