New Haven Independent

Instead, Marna Borgstrom is looking at the fine print: Will Congress put enough dollars behind Medicaid as it includes millions of more Americans in the plan? Will enough money be put into digitizing health records to truly connect different health care institutions?

And she’ll be looking at what considers the bigger picture: Whether cost-cutting will enable true health care reform to succeed in the long term, or whether a lack of attention to changing the way people use the system makes any reform plan “unsustainable.”

“If you don’t fix Medicaid and you don’t get enough of the uninsured covered,” Borgstrom said, “the numbers simply don’t work.”

“Demonstration Projects” Needed

The scheduled vote by the Senate Finance Committee Tuesday on a proposed $829 billion health care system overhaul marks not the end, but rather a new stage in a tumultuous debate. If the committee’s bill passes as expected, senators and congressmen will then reconcile five different committee bills to bring a compromise version for a final vote.

As that debate progresses, Borgstrom is watching with a distinctive vantage point and institutional self-interest — as the CEO of a $2 billion-a-year hospital system that cares for 90,000 inpatients and over 1 million outpatients a year.

In an interview in her office Monday, Borgstrom said she considers the top priority right now “to cover virtually all Americans.”

Most attention has focused on which plan would best do it at the most reasonable cost: A “public option,” featuring a federal government-run insurance plan, or a variant with an “opt-out” for states? Health insurance “exchanges”? Regional cooperatives? Wider use of lower-cost catastrophic plans? (The Senate bill would raise the estimated percentage of insured Americans by 2019 from 83 to 94 percent, leaving 25 million people still without coverage.)

Borgstrom said she doesn’t favor one plan over another. She’s more concerned about the goal — and the way the government decides to pay for it.

For instance, any savings expected in the plan could prove illusory in the long run without changing the way people take care of their health or when they decide to see a doctor, she argued.

“If we just cut what we’re paying providers, but we have an aging population of people” who continue eating badly or smoking; and “[we’re not] making concurrent investments in the front end of the system with younger people, I don’t think you’ll get sustainable change.”

Borgstrom proposed that the feds pay for experiments to test different models of providing incentives for institutions to keep costs down without sacrificing quality, and to encourage people to live more healthfully, get preventive care, and see doctors in time when problems develop.

No one has a magic-bullet solution yet, she said.

“Right now we get paid for the acute care episode. Physicians get paid for what they do. Long-term facilities get paid for what they do. Home care gets paid for what they do. But there are not good incentives and opportunities to tie elements of the system together so that we can really figure out” how to deliver better care for the dollar … Everybody agrees that unnecessary admissions or readmisisons is a bad thing. It’s easy to say, ‘We should cut unnecessary admissions or readmissions.’ To actually figure out what will have a causal effect on that is much harder.”

The Medicaid Specter

Any final health reform bill is expected to cover more Americans in part by increasing the number who qualify for Medicaid, the government insurance program for poor people.

As the hospital that serves the most poor patients in the state, Yale-New Haven says it ends up spending $100 million a year to cover too-low Medicaid reimbursements as well as charity care and care for the uninsured.

None of the proposals before Congressional committees has addressed how to pay for increased Medicaid coverage, Borgstrom noted. That makes her nervous.

“There’s sort of an implicit assumption — though I don’t believe lawmakers believe this is the case — that Medicaid is as homogeneous a program as Medicare is,” she said. Unlike Medicare, which has federal funding formulae, “Medicaid is a state-by-state issue. So in the state of Connecticut we have a pretty well-funded Medicaid program. But how we spend Medicaid dollars in this state is much different from how they spend it in even New York State or Massachusetts. We spend a much larger percentage of the Medicaid dollar in this state on long-term care, less of it on acute care or physicians.”

Borgstrom said she “absolutely believes” that any final health reform bill will end up increasing that $100 million uncompensated care tab for Yale-New Haven because of the Medicaid expansion.

A Longer Digital Road

Borgstrom also expressed skepticism about another key assumption behind the emerging reform consensus in Washington — that digitizing health records will pay a significant chunk of the cost of covering more people.

She does support the idea of moving from paper to electronic record-keeping and linking systems so doctors can find out a patient’s history. The hospital has been doing that. Its new Smilow Cancer Hospital will start out with all-electronic notes and nursing and physician notes.

In practice, health-care institutions are finding that it’s difficult to link up with other institutions to get a patient’s history.

“I think everybody is underestimating how difficult it is going to be to bring all those systems up and how difficult it is going to be to make them interoperable so that you’re really getting a private physician’s office information integrated with a private radiologist integrated with our emergency room,” she said. “Everybody’s on a different system. These systems, as good as they may all be, don’t inherently talk to one another.”

There’s also the “challenge” of still making sure everyone treating a patient reads the electronic notes, she added.

But she also suggested that the answer doesn’t necessarily lie in just having the government pour more money into digitization. Individual institutions need to invest, too. “We can’t make us all strategy cripples who only do the right thing because we depend on governmental funding,” she argued. “I think we have to build in incentives to get the providers working together.”

Cadillacs Not The Answer, Either

Borgstrom was just as skeptical of the “Cadillac” solution — that a meaningful chunk of the tab for near-universal care can come from taxing generous health benefits that cost more than those offered by an eventual government-backed plan.

It’s difficult to define a “Cadillac” plan, she noted. She also noted the “interesting bedfellows” fighting the idea: labor and big business.

She has personal reservations about the wisdom of the idea, as well.

“I think that it starts to feel like the government coming in and saying, ‘Everybody’s entitled to this much care,’” Borgstrom said. “I don’t the government will do that. Because I don’t think people can be elected or reelected if they start defining benefit levels and rationing health care …

“[And] to just tax organizations that may have done the right thing — whether it’s advocating for employees in the case of organized labor or responsible employers — I’m not sure that feels very good.”