--A Q&A with Yvonne Goldsberry and Lucy Hodder

With rising costs and a complex mix of different players involved in the delivery of care, how can New Hampshire create a trusted, sustainable and equitable healthcare system? Endowment for Health President Yvonne Goldsberry together with Lucy Hodder, Professor of Law and Director of Health Law and Policy at the UNH Institute for Health Policy and Practice, discuss collaborative efforts to achieve system accountability and build on the lessons learned in the era of COVID-19.


Tell us about the reBuild Health initiative and its priorities

Yvonne:
For decades now, I've been asking why healthcare costs so much in our state and wondering who is paying attention to that dynamic. Several years ago, Lucy and I had a deeper conversation about this. We’ve explored the regulatory environment, but it doesn’t really answer some fundamental questions – like why we pay for hospital and specialty care, but not for primary care in the same way other states do. For small companies, premiums keep going up and there’s often not even a choice for a low deductible plan. Ultimately, the burden of the cost of care ends up on us as individuals. The dollars we spend in healthcare are dollars that could be used to improve health. Other states that closely monitor their healthcare system’s cost information have a better ability to balance what gets paid for.

Lucy:
People need access to healthcare. We need options, and those options need to be cost effective. What’s the solution? Ten years ago, conversations about how and why to reduce costs and improve quality were everywhere, but have since been quiet. Why aren’t we making more progress? Every time we dig deeper, we find a messy tangle of rules and obstacles both seen and unseen. That’s why we began the reBuild initiative, bringing together insurance professionals, health policy wonks, legal experts, patient advocates, providers, and associations. Participants wear multiple hats, sharing current and past experience. The key is setting aside our vested interests in order to have an honest conversation about our healthcare system.

What is driving the cost in New Hampshire?

Yvonne:
New Hampshire is a high-cost state as compared to both the nation and the region. The data shows that pharmaceutical costs are a big driver, but it’s more than that. Big providers can essentially name their price. But prices differ from actual costs. Unit prices are going up faster than inflation. Utilization is rising a little bit higher than the national average, but not enough to drive the change in prices. So it’s not that people are using more services.

Lucy:
New Hampshire is higher than other states and the nation on pretty much every indicator of healthcare costs. Higher deductibles, higher premiums, more mergers, higher hospital inpatient and outpatient prices, and faster cost increases. People don't have the money to do other things in their lives because of these costs. Our wage growth is stagnant because of the constantly increasing dollars going into healthcare. It overwhelms other opportunities.

And you can't say it’s because we're sicker in New Hampshire – that's true everywhere. We do have an aging population, but so do many other states. It’s true that we're a very small state, so we don't have a large population over which to spread the insurance risk. But our biggest businesses are healthcare providers. We don’t have other large companies able to negotiate for cost efficiencies and quality improvements in the healthcare system. People who purchase healthcare think there’s a market-competitive economy associated with it, when in fact, all these different incentives and different regulations create a complex and tangled mess. Healthcare delivery is not a typical market. Left as is, costs will continue to increase.

How do hospital mergers figure into the equation?

Lucy:
There may be really good reasons why healthcare mergers and consolidations need to happen. But we also know that mergers tend to drive prices up. Mergers and consolidations have other consequences as well. We're seeing it firsthand -- closure of maternity services, price changes, loss of lower cost options, the disappearance of primary care in certain regions, duplicative services opening up and then others going out of business. So we see lots of changes, some of which may be necessary, but who's to know and who’s deciding whether this is good for our health or not?

Yvonne:
And there are too few resources to examine the potential consequences of mergers in our state. Once mergers are approved, there needs to be more analysis of the long-term effects of these deals. An oversight group could ask deeper questions. We don’t have anyone minding the store to figure out what our communities really need for healthcare services. We need to go beyond just asking if we should merge or sell hospitals. We should ask what certain areas of the state need for healthcare. We want our hospitals because they are often our largest community asset and communities have invested so much in them locally.

But it’s healthcare in general that’s the big economic driver – not just hospitals. Maybe the community needs a well-run urgent care plus deep primary care, community wellness programs and maternal-child health services. There are lots of ways to keep our communities healthy.

How has the pandemic further complicated healthcare access and delivery?

Lucy:
During COVID, our state and federal governments exercised emergency powers just to get telehealth to people or to get emergency sites open for COVID care. We have mountains of federal and state regulations that have been waived to allow for COVID response. The pandemic showed us we need to redesign how we provide the care and how we oversee it. The pandemic also revealed how deep and wide the healthcare crisis is and just how different our experiences can be depending on who we are and what we need.

Hospitals really came together to procure ventilators, defer elective procedures and address the spike in acute care. But in terms of meeting the community’s public health needs around vaccinations and tests, that's been picked up by urgent care facilities, pharmacies, public health departments and the National Guard. So we can learn from the pandemic how to deliver the right care at the right time in the right place. But it shouldn’t take a worldwide pandemic for us to plan and collaborate.

What type of oversight might improve the healthcare system for providers and consumers?

Yvonne:
The reBuild group took a hard look at what other states do to keep their costs in check. They often have different levels of oversight without having full-blown regulation. And we’re starting from a good place because New Hampshire already has one of the best data and cost transparency systems in the nation. We collect information through our all-claims database. But other states go beyond just collecting data. They invest in analyzing that data and they invest in creating targets and goals informed by the data. That’s the next level up for New Hampshire – adopting an oversight model. This would allow us to better inform the public and policy makers about cost trends and how they affect the service array in our healthcare ecosystem.

What else can we learn from other states?

Lucy:
What’s so different about New Hampshire and what is holding us back? Other states like Maine and Rhode Island have set guidelines for total healthcare investment, and as a result, they are looking to ensure adequate investment in primary care. Maine doesn’t want legislated regulation any more than New Hampshire, but they do set healthcare goals based on the data they collect. Maine businesses were in the conversation, using their clout to say, "We want enhanced primary care, we want integrated behavioral health. Where's our collaborative care?”

Data analysis isn’t meant to punish any stakeholders. It’s about better and more equitable decision making. For instance, we should be looking at what’s happening to premiums, healthcare spending and utilization. This type of analysis is very important. Look at the past year. Few consumers got healthcare last year due to the pandemic. Now we need to prepare for sicker people returning to the system with significant physical and mental health issues. Without knowing how much we recently left on the table across all our payers in New Hampshire, we don't know how to prepare for next year. A centralized place to talk about these dynamics will help us plan and collaborate.

Yvonne:
There’s also the work in Rhode Island to consider. They have a lighter form of regulation that's brought about some real synergies that impact the healthcare system. Maryland is at the other end of the spectrum from Rhode Island with rate-setting. But all these examples have brought in multiple stakeholders to solve the problem. We can't say that only one part of the system is responsible for the whole system’s complexities. It’s not just the insurance companies or just hospitals or just providers or just patients. It’s all of it together which is what makes it a hard and necessary dialogue.

What should be done in NH to increase access, improve quality and decrease cost?

Lucy:
The reBuild initiative identified priorities around health equity, long-term financial planning, accessible and affordable health insurance and enhanced primary care. It’s about setting priorities where the actual need is. For instance, why can't we make primary care and mental health the system priorities and reward them financially? If healthcare were a market economy, it would look very different. For instance, the demand for mental health is huge. We'd be paying psychiatrists more than other specialists in a true market economy because we’d be operating on supply and demand. So why don’t we pay that way? It's because some of the work is not valued as highly. No one is willing to pay for the services most in demand and then take less in other parts of the system.

On the patient side, if someone's having suicidal ideation and they’re in crisis, copays should not be what prevents them from getting help. If we think these things are important, we should find a way to ensure we can offer those services to patients without risky financial barriers.

These are just a few examples of why we need an accountable group to look at our needs and structure the system accordingly. That’s why the reBuild table has been a safe place where we can all talk about what different stakeholders need to contribute. It’s about creating trust in the collaboration so we can honestly discuss incentives.

What are the long-term implications to our economy if we don’t put greater focus on addressing healthcare costs?

Yvonne:
We don't fully acknowledge the wage suppression that happens due to high healthcare costs. In New Hampshire, we don’t pay taxes, but salaries are often capped because of high health insurance premiums. They’re also capped in total compensation because we're paying a big portion into healthcare. We're going to hit a point where we have even more trouble attracting a workforce because of the high cost of healthcare and housing. That’s going to become unsustainable very quickly.

Lucy:
Our current trend is not sustainable for us individually or collectively. If you look at how much we pay out-of-pocket, individuals are paying huge deductibles and a big chunk of their premiums, on top of other costs. The expense leads us to defer or forego care. Then we get sicker and go in the hospital with more issues and co-morbidities. It's not a good scenario and businesses won’t come to New Hampshire if they can't find employees and can’t pay for healthcare. As healthcare consumers, we should expect payers and providers to explain their market decisions to us, because we pay for them to organize our benefits. We're not just quiet, unsuspecting recipients of their good graces. People are paying thousands of dollars out-of-pocket for care, so we deserve to have our every question answered.

What other questions does the reBuild work raise?

Yvonne:
I’ve learned in this process about the fallacy of cost shifting. We often hear that the public system doesn't pay in enough. Therefore, we shift the cost to the private insurance market. Yet other states prove that this isn’t always true. The claim is that Medicaid and Medicare don't pay enough, and therefore, we have to make our money somewhere else. Changes do need to be made in the reimbursement structure, but there's tons of nuance in how Medicare and Medicaid pay. They don't pay a living wage to all the different kinds of providers. Some providers get paid a little more than others. If you adjust for that, our private system still is gouged. Why is that happening in New Hampshire when other states see that to a lesser extent or simply don't allow it? The creation of an oversight body would ask these questions and press for a solution.

Lucy:
The RAND study data was very interesting as well. It highlighted the lack of rewards for areas of our healthcare system that are getting good results. We need to look at what's working well and where it’s happening in our state. We have community providers reaching out to patients and working with each other offering help and support at low cost. Some hospital systems in New Hampshire do try to contain costs and ensure consistent support for inpatient, outpatient and community services so the system works equitably. We need to take note of those examples and reward them.

Is there hope of rebalancing the healthcare system so it works better for everyone involved?

Lucy:
Yes. There are some glimmers of great hope. Being a small state works against us in some ways, but on the positive side, everyone knows each other. It shouldn’t be at all difficult to get out and listen to what patients want across the state or to get 13 CEOs in a room. And we’re small enough to look to our partners in the region and find ways to collaborate across borders. In New Hampshire, when we put our mind to something, we make things happen.

Yvonne:
Which brings us to why the reBuild initiative has a shared vision for creating a trusted, sustainable, and equitable system. The first step is to have an accountable body watching and looking, even if it's not regulating. We need to analyze the data we already have and start setting some targets. If we just do that, it will be a huge step forward. We’d be shining a light on all the complexities in the healthcare system. And we’d stand a good chance of leveraging collaborative solutions.

What are next steps?

Yvonne:
We’ll be digging deeper to research and assess our state’s healthcare ecosystem and take steps to amplify the patient voice. We’ll also work on understanding the possible models that are achieving better outcomes elsewhere in the country. Our ongoing work is likely to encompass several departments, not just the Department of Insurance, and not just the NH Department of Health and Human Services. We’ll be engaging with many different stakeholders, including the Department of Business and Economic Affairs, the hospital systems, the business community, and many others. Healthcare hangs in all of those spheres.

Lucy:
And we’re going to keep talking about this. As consumers of the healthcare system, now is the time to ask, is healthcare there for us? Are we being represented? Is the system meeting our needs? If providers and payers can analyze data and plan for how to treat a population of patients with diabetes, shouldn’t we expect the same kind of data analysis and planning for the overall health system? Shouldn't we have that same accountability and opportunity at the big systems level where big dollars are at stake and the big decisions are made? We know the answer to these questions. And we can move closer to accountability with the creation of a coordinating authority or oversight body. That’s what’s needed to bring trust, equity, and sustainability to our system of care. We’re committed to continuing the reBuild conversations across New Hampshire with more people and stakeholders to get it done.