"Is it in the Water? Others Look to Massachusetts' Not-for-Profit Health Plans to Improve Quality" by James Roosevelt, Jr.

Next week I am traveling to the northern Virginia suburbs of Washington, D.C. for a panel discussion hosted by the National Commission for Quality Assurance, which is best described as the body that assesses health plan quality measures. Its credibility is unquestioned and its partnership with U.S. News & World Report results in the magazine’s eagerly anticipated annual best health plans issue, which reveals the good, the bad and the ugly among roughly 400 participating health plans.

The audience for our discussion is a national gathering of CEOs, physicians, other health insurers and legislators.

Representing Tufts Health Plan, I will be sharing the stage with Charlie Baker, CEO of Harvard Pilgrim Health Care, Eric Schultz, CEO of Fallon Community Health Plan, and Dolores Mitchell, executive director of the state’s Group Insurance Commission, who will moderate our discussion. All are familiar to readers of this space. The topic of our conversation is “Quality Realized: Insights from America’s Best Health Plans.” These three Massachusetts-based, not-for-profit health plans rank among the best in the nation, a distinction worth noting, and apparently of great interest to NCQA’s guests.

Our country’s leaders look to much of what is already in place in our state as guidance for developing national health care reform. There are a number of provisions being discussed at the national level such as guaranteed issue and no pre-existing condition exemptions, which we take for granted but constitute a huge leap for other states. I believe that this framework of inclusion is based on fundamental fairness, which originates from our citizenry’s values and the predominance of not-for-profit health care institutions whose highest priority is the delivery of quality health care to patients, and not-for-profit health plans, whose highest priority is service to their members, not shareholder dividends.

For example, Tufts Health Plan works to manage medical trend so that care is neither over delivered nor under delivered in order to improve quality and keep costs as affordable as possible. Having similar, and in most cases the same, provider networks as the other not-for-profit health plans, contributes to our costs but our customers tell us that they want hospital and physician choice.

Instead of competing with network designs, not-for-profit health plans compete for business based on our prevention/wellness programs and our medical management, which is central to our core quality efforts. This focus results in lower costs. We reinvest resources into partnering with providers for clinical improvements. And, benefits, which cover high cost care such as infertility treatments, remain rich compared to what is available in other parts of the country. Moreover, the Commonwealth’s excellent hospitals do not turn away people because they can’t pay—this can’t be said in many other states.

I recognize there are readers who will claim I am being wrongly self-congratulatory as the American health care system doesn't work for many Americans. Of course, I am well aware that the system is seriously flawed and that there is ample opportunity for improvement. That is why I am such an advocate for the approach of not-for-profit health plans--and our national quality rankings support my endorsement. We have shown that within the current framework we can provide access and coverage in a manner that improves quality care. Can we do things better? Yes, of course. Doesn’t working with the foremost physicians and hospitals in the country contribute to high quality? Yes, of course; they are central to delivering the high quality care that all of us expect here. Aren't health care prices unsustainable? Yes, of course. Is health care a right? Again I would say, yes, of course. The good news is that we have an administration that shares the belief in the fundamental right of access to health care for its citizens and the momentum exists for meaningful change.

In the end, I believe that on a local and national level we must continue our focus on finding ways to rein in unsustainable health care costs by creating public policy that supports disclosure of quality and cost information, focuses on prevention and wellness, improves technology in health care and works to eliminate waste in the system. At the same time, we should also take a moment to recognize the value of what we have in our own backyard. It's worth noting.

James Roosevelt, Jr.
President and CEO
Tufts Health Plan