This is the transcript of my recent podcast interview with Martha Coakley, Attorney General and Democratic candidate for Governor of Massachusetts. Visit the original post to listen to the podcast and read a summary. This is part of a series of interviews with all nine candidates for Governor. The full schedule is available here.
David E. Williams: This is David Williams from the Health Business Blog. I’m speaking today with Martha Coakley, Attorney General of Massachusetts and candidate for Governor.
Martha, does Chapter 224 represent the right approach to addressing rising healthcare costs? And if not, where does it miss the mark and what would you do differently?
Martha Coakley: Thank you, David. Thanks for chatting today about this very important issue, not just for Massachusetts but for the whole country.
Every piece of legislation is a little bit of a compromise. A lot of thought and effort went into this particular bill – including work from our office – around what we thought was important to make sure that we were going to continue in Massachusetts to provide access to good quality care for everybody, but addressing this important issue of how to contain cost.
The legislation does a very good job at addressing, for now at least, the major issues that we wanted to provide for the legislature: accountability and transparency, so that people start to get educated about what they need to know about healthcare, but also set up how we can measure whether it is working or not and how we can look at it as we try and move to more accountable care organizations and more prevention. Can we save cost? Can we get better outcomes?
This statute is the right way to go for now. I know that with the Health Policy Commission, with the CHIA, and with our office still looking closely at this very volatile market in healthcare, it gives us the tools in the short run we need, but also gives us the flexibility that if we need to change it later, if we need something else, that is built in to this legislation.
Williams: There are certain provider systems in Massachusetts that are reimbursed significantly more than others for the same services even though there are virtually no differences in quality. In your view, does the state have a part to play in addressing these disparities?
Coakley: When I came in [as Attorney General], we set up our healthcare division, because we knew that implementing the new healthcare law would require expertise in our office to make sure it was done right and effectively. We spend a lot of time taking a look at this less-than-transparent market. As my folks said, we want to take a look under the hood and see what the market looks like to see why it was so expensive.
One of the things that we found was that, in fact, because of what we deem to be market dysfunction, there was an ability of some providers for instance to get reimbursed at different rates than others because of their marketing clout. We did look at how a knee might cost one thing in hospital X, something else in hospital Y, and yet the outcome for the knee was the same.
We developed the concept of total medical expenses and metrics to measure the value of what hospitals are doing, particularly in areas that you can measure. That opened up was the whole idea that we have a system that is based on a fee for service. We needed to look at whether they were being reimbursed in a fair way for the total medical expenses involved in that service. It also opens up the much broader risk that we already talked about in moving away from that to looking at more prevention and ways to save costs.
Williams: There are more than a dozen state agencies that have a role in healthcare. Is there an opportunity to consolidate or rationalize them?
Coakley: One of the things we’re doing right now is looking at exactly how the state itself can be more efficient and effective in both changing and working with how the market is going, and doing the oversight on that. The statute, in setting up these two new commissions, the Health Policy Commission and the CHIA to look at what the market is doing in somewhat real time is an important place to be right now. One of the things that’s important to me as AG and would be as Governor would be to take a look at how we are structured at the state level both in terms of what the mission is of different agencies and other collaboratives or commissions. Is there overlap? Is there regulation? And are we being duplicative in any way in trying to address this?
I think for now, we’re still looking at the changing and volatile market, we’re trying to keep track of it. I think we have the right ways and sets of eyes on it but that’s something any Governor, and I certainly would be focused on in the years going forward. Do we have the right ways that we’re trying to monitor this market and make sure that we’re cutting that cost curve and continuing to provide access and quality for people?
Williams: Government policy both at the federal level and the state level has encouraged the adoption of electronic medical records. However, many providers complain about the systems and the benefits have been slow to materialize. Should state government play a role in helping to realize the promise of health information technology?
Coakley: It’s pretty clear that we need to make an investment in technology that will let us have quicker information, and make sure that all of our providers are able to do this. There are a couple of advantages. It means that when people travel around in different systems, that people in real time are able to look what medical histories are, even within the same institution making sure that we are using doctors’, nurses’ and paramedical folks’ time and energy most effectively, and frankly, with better outcomes for patients.
It is a big investment. Like any change from an older technology to a new one, it’s refueling in air, it’s hard to do. It’s crucial and I do think the state has to both provide assistance where it can and incentives to make sure that we do invest in that technology.
The other issue around this is as we become increasingly technology-savvy, we’re also more concerned about keeping information confidential, particularly in this area, where patients’ information is so crucial. And as we’ve seen, data breaches are very serious, including with hospital information. We have to be conscious of the ability to share that information in electronic records, but how do we provide the safeguards both for the patient-physician confidentiality and what patients expect?
Those will continue to be challenges, but it doesn’t mean we stop moving forward on making sure we invest and we get both the best of electronic medical records so people can share in the information and protections to make sure that’s not abused.
Williams: Hepatitis C is three or even four times more common than HIV. There are new drugs that can cure the infection that are coming on the market this year but they’re very expensive. What role should the state play in ensuring that residents are tested, linked to care and have access to these new medications?
Coakley: That’s a good example, and it’s not the only one, of where new developments in drugs are helpful and pharmaceutical companies spent a lot of money investing in them. They have a patent. They want to get their return on the investment. But we also need to make sure that it is available to people who need it, and the state obviously has to play a role. And that’s the whole idea behind what we’ve done in healthcare reform. It’s making sure that people have the coverage they need and the access to go to doctors.
But obviously, in this instance and in some situations where we have what we call orphan diseases – where they’re rare, there’s not been a lot of investment in them, the advances are very expensive – the state definitely has to make sure that we are able to subsidize for people the medications they need, particularly if their doctors are recommending it. And you will get a better outcome across a range of cases and in individual cases.
Williams: There are multiple healthcare-related ballot questions. What are your thoughts about them?
Coakley: There are two ballot questions. They really address management issues and public issues. They’re both appropriate topics for public discussion. I’m very sympathetic to nurses’ concerns about being able to perform their duties in the right timeframe, with the right resources and to be able to manage their patient care, which is important, as well as make sure that patients also get the right treatment.
I happen to think that this area of discussion right now continues with individual hospitals and nurses. Trying to get a ballot determination on it may not be as easy as people think. But I certainly think the topic is a good one for discussion and I continue to support nurses and frankly, others, who were saying, “we need more help, we need more support to do our jobs right.” Their concern is about patient safety and patient care. And all institutions should be concerned about that.
On the second question, of course, in our office, we have a Charities Division, a not-for-profit division. We played a big role in looking at some of the compensation issues for CEOs and for boards in terms of not-for-profits. That discussion has begun a very healthy talk about what is the appropriate range for boards to make determinations. Boards of not-for-profits, which are most of our hospitals and healthcare institutions, have a very serious job to play in making sure that the assets of the charities are being used responsibly.
It doesn’t mean they can’t compete to pay for the type of leadership they need. We’ve had long discussions about the compensation issue for board members of not-for-profits. I’ve been pretty clear about that. But I do think, above all, that transparency is important and that the public should know. And we’ve played a big role in the Attorney General’s Office in making sure that those compensation issues are made public.
Again, we’ll see what happens with that ballot question but I think we began a good discussion and that it’s important for the public to know about compensation.
Williams: We’ve certainly been discussing extensively in this interview the role you played as Attorney General relative to healthcare. Are there specific things that you’ve learned about healthcare as AG that will be useful as governor?
Coakley: Absolutely. I mean, coming in eight years ago as an Attorney General coming from the District Attorney’s, there are a lot of learning curves for me around healthcare, utility regulation, the importance of energy and conservation. But particularly in healthcare, it’s been a very interesting and actually rewarding journey for me to see how unique Massachusetts is and the relationship we have with our elected officials on both sides of the aisle, with our not-for-profit healthcare providers and insurance companies and our for-profit providers. We have an advantage here in Massachusetts that we didn’t say, “Should we provide access to coverage for people and good quality healthcare?” We said, “How are we going to do it?”
That relationship continues through this time period. Most states don’t have that. I think the next Governor of Massachusetts, and I would certainly take advantage of that, has a huge opportunity now to continue to cut cost curves and look at better ways that will provide for better prevention, better coverage, and cutting cost drivers like diabetes and asthma, for instance. What I’ve seen about what’s worked so far and where we need to go as AG will be immensely helpful as a Governor in continuing not only for Massachusetts but as we struggle with this issue across the country, making sure we continue to lead in providing the best in healthcare for everybody here in Massachusetts.
Williams: Much of the emphasis in healthcare reform is placed on adult patients. Do you think there is a need for a specific focus on children’s health?
Coakley: I absolutely do: pre-natal care, early education and care at that stage for kids. I’ve spent – as many folks know – a lot of my time working with kids in the child abuse unit and as a district attorney. I understand that the issues around pediatric wellness are very different from that of adults and how well we get kids to thrive with nutrition and with good emotional care is really important for the well being of children.
One of my colleagues had a daughter who had the norovirus two weeks ago. He was very glad that he could bring her to a pediatric emergency room, which not all hospitals have, because the doctors and the nurses are going to know that for parents and for children, issues are highly emotional and good care is required.
We have the Children’s Hospital and our other facilities here in Massachusetts, we also have an emphasis on the wellness of children. And I’ve said, quoting the Children’s Hospital jingle, “until every child is well”. We should have the focus on till every child is physically and mentally well. It’s incredibly important to focus on wellness and prevention for children.
Part of the move towards more prevention is going to pay attention to those issues as kids do develop asthma and diabetes. Those two start at an early age. We can save money down the road if we focus on pediatric issues and make sure that we provide kids good healthcare when they’re sick and good prevention to help them be healthy adults.
Williams: I appreciate you answering all my specific questions here about healthcare. I also want to give you an opportunity if there’s anything else that you would like to add that we haven’t covered today.
Coakley: I would like to talk about the idea of mental health and behavioral health and how this is the time to try and reduce that stigma around getting help for people who have depression or bipolar or behavioral addiction and focus on that.
I’ve told this story about a younger brother, my younger brother Edward, who suffered at age 17 from depression and bipolar. Very smart, talented, good pianist, but wouldn’t get help. And after refusing help and medication, because he was afraid the stigma would prevent him from getting a job – he actually couldn’t hold on to a job, couldn’t maintain relationships – and after my parents died, 18 years ago, he committed suicide. I’m very aware of that struggle, for my family and for Edward. And I know that people and parents and returning vets around Massachusetts suffer from this.
In 2014, Massachusetts, with our great doctors, with our advances in biopharmaceuticals should be able to both reduce that stigma and make sure people have access to [mental health care.] It is about time we recognize it. I’ve had the personal experience of it. As I mentioned earlier, both for kids and for adults, letting them know that getting help for a mental or behavioral illness should be no different than getting help for diabetes.
Williams: Martha Coakley, Attorney General of Massachusetts and candidate for Governor, thank you very much.
Coakley: Thank you, David. My pleasure.
—March 6, 2014