Now that Americans by the hundreds of thousands are signing up for health insurance coverage, reformers are moving on.
• They want high health care prices to be disclosed and driven downward.
• They want the most effective care providers identified for the public.
• They want a medical extension service to get best-practice ideas out to busy providers in stressed rural areas.
• They want mental health care to be better coordinated with primary medical care, so communities no longer have to use jails as mental hospitals.
Last week, as Washington’s Legislature wrangled its way to adjournment, Gov. Jay Inslee and other advocates for health care reform declared themselves to be more or less pleased: It took a fight, but lawmakers passed bills to start implementing every one of these ideas.
The agenda for this second stage of health care reform came from the state’s Health Care Innovation Plan, a 298-page strategy that was funded by a $1 million federal grant and crafted by a coalition of Washington health care interests: hospitals, doctors, nurses, mental health clinics, tribes, University of Washington Medicine, small and large businesses that buy coverage for their workers, consumer advocates, most health insurance companies, and the agencies responsible for public health.
The innovation plan projects $730 million in savings over three to five years. The revised state budget that the Legislature approved last week counts on some of those savings, which are attributed mostly to planned improvements to the state’s mental health care system. Even the state officials who oversee that system describe it as so complicated and bureaucratic that it makes care difficult to obtain, costly to deliver and not very effective in terms of public health.
Rep. Eileen Cody, one of the Legislature’s leading advocates for health reform, works in the medical system when she isn’t agitating to change it. With 35 years as a registered nurse, she works in a Seattle clinic and specializes in treatment of neurological problems such as strokes, spinal injuries and multiple sclerosis.
Mental health care
“As a nurse,” Cody said, “I see people who if they don’t get their mental health taken care of, they’re in the doctor’s office all the time. Integration of physical and mental health is happening all over the country, and it’s about time. For a long time mental health wasn’t treated as if it was health care. Finally we’re starting to see the whole person.”
As chair of the House Health Care and Wellness Committee, Cody was deeply involved in two of the main health reform bills the Legislature passed this year.
The first bill, and one of the least publicized, was Senate Bill 6312. It calls for the state’s Medicaid system to change the way it purchases and delivers mental health and substance-abuse treatment.
But the goal, to be achieved over several years, is about more than contracts. It’s to transform the clinics where Medicaid recipients get their care. Specialists in psychiatric care, the bill provides, ought to begin working side by side with the nurses and doctors who help patients with medical issues such as heart disease.
Jane Beyer, assistant secretary for behavioral health and integration at the state Health Care Authority, cites the example of a mother who arrives at a clinic with a pair of troubled teens: While the mother gets help with her diabetes, the teens could visit mental health and substance-abuse counselors, and all three might check in with a social worker.
Dorothy Teeter, director of the Health Care Authority, said the goal is to drive down the costs that result when patients in a fragmented system can’t figure out where to get help, stop taking their mental health medications, and then behave in ways that damage their well-being and sometimes even get them jailed. Jail stays resulting from missed medications are as preventable as they are expensive, Teeter said. And jails aren’t designed to deliver medical care.
The bill to increase collaboration between behavioral and medical services passed easily, 48-1 in the Senate and 75-22 in the House.
But this year’s other major health reform proposal did not fare so well. House Bill 2572 faced intense opposition from Premera Blue Cross, the state’s largest health insurance carrier.
Price database attracted opposition
Sponsored by Cody and backed by the same coalition that crafted the Health Care Innovation Plan, the bill called for a database of statewide claims for health care payments. It would expose what Washington’s care providers are paid for common services and how well those services turn out in terms of patient health. In Washington, fees can vary up to 500 percent from one provider to another.
Consumers could use the database to identify the most cost-effective doctors and hospitals. Employers who provide self-insured coverage for their workers could use the database to choose which providers are in their networks. Public health officials could use the database to identify communities with weaknesses in their care delivery systems.
Databases like this operate in 10 states and are being developed in several more.
The original bill made it mandatory for all carriers of health coverage to contribute their data. Most insurance companies did not object, but Premera did. Arguing its information is proprietary, Premera lobbied hard, Cody said, and won support from the Legislature’s Republicans.
After passing the House, the bill hit rough sledding in the Senate, where Republicans dominate. Randi Becker, Republican chair of the Senate’s Health Care Committee, stripped the database provision from the bill. Following a Spokesman-Review story about that maneuver, controversy erupted. The Senate Ways and Means Committee then adopted an amendment restoring the database but placating Premera by making database participation optional instead of mandatory.
Thursday on the Senate floor, Democrat Karen Keiser tried to broaden participation in the database by proposing an amendment that would require it to contain claims from health coverage for public school teachers. Senate Republicans killed the amendment. “Guess who insures school employees?” Cody said. “Premera.”
Without mandatory participation in the database, it will show an incomplete picture of the state’s health care market, Teeter has said.
The only claims guaranteed to be in the database are those from her agency, which oversees coverage for state employees and the rapidly growing Medicaid system. Still, that’s not a small number; it involves care for 1.7 million people, about a fourth of the state. Plus, major self-insured employers such as Boeing and Alaska Airlines, which backed the innovation plan, might participate voluntarily in the database.
Medical extension service
Less controversial than the claims database was a requirement in Cody’s bill for creation of a medical extension service. Like the extension service that sends agricultural research to farmers, the medical extension service could tap the latest University of Washington health care research and share it with busy clinicians in Washington’s small towns and rural hospitals.
A federal grant being sought to implement all of the innovation plan’s reform initiatives would pay for the effort.
As evidence this could help, Cody has cited legislation she pushed through in prior years to provide Washington’s physicians with research-based decision-making protocols that reduce unnecessary imaging tests and cesarean sections.
As the legislative session drew to a close Thursday, the amended HB 2572 passed by a bipartisan margin of 32-17 in the Senate and 70-27 in the House. Inslee and Teeter hailed the result as a framework to “put our health delivery system on a solid path toward better health, better care and lower costs.”