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zoom RSS 高騰する医療費問題に直面するマサチューセッツ/米国医療事情

<<   作成日時 : 2009/03/17 19:57   >>

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 3年前、マサチューセッツはアメリカの歴史上最も豪快な医療実験を開始し、あっというまに皆保険をもたらした。民主党議員と共和党のMitt Romney知事は、暴走する医療費を制御する努力を延期し、ついに決算期を迎えた。
 新たな助成を得た保険プログラムへの急速な登録と、今や急速にしぼむ経済に脅かされて、いよいよ第2のより挑戦的な段階に達した。
 昨年課された新税と料金のおかげで保健医療計画の財源はさしあたり安定したが、政府と企業役員は、医療費の増加を阻止する重要な処置を取らないと、今後5-10年間持続可能とはならないだろうということで意見は一致している。
 ワシントンの様子を窺いながら、州の指導者は再び新たな実験を始めている。
 Romney氏の後継者で民主党知事のDeval Patrickと州委員会は、公的私的保険の医師・病院への支払い方法の変更を試みている。予防と慢性疾患の効果的なコントロールに対して対価を払う新たな方法を探っている。マサチューセッツが、この変換をする最初の州になるならば、皆保険と同じくらい大胆な業績だろうと専門家は言う。メディケイドは州と連邦政府が共同し、メディケアは完全にワシントンが財政支出をしていることから、州にとって実現するためのハードルがある。
 2006年の皆保険の制定には、重い原価管理を必要としていたなら実現可能ではなかっただろうと言う。医師、病院、保険業者、および消費者グループは、収益が減り医療が強制されれば、反対の表明しただろう。その保護のために莫大な投資を必要とした。
画像 しかし、医療費削減はこの州の長い伝統により困難を伴う。マサチューセッツは人口一人当たり最も多くの医師がおり、ボストンは国の最も高価な学究的なメディカル・センターのいくつかの本拠地であり、新しい州法は処方薬と精神衛生保険補償のような包括的な給付を必要としている。Alan Sagerボストン大医療政策教授によれば、マサチューセッツの一人あたり医療費は最近の8年のうち7年で全国平均を上回っている。その差はマサチューセッツでは指数的に増大し、1980年には全国平均より23%増だったが現在は平均より1/3多いという。皆保険にするには最も容易な場所であったが、原価管理をするには最も難しい場所であるかもしれないと、MITの医療経済学者Jonathan Gruber は言う。
 しかし、Patrick氏は、州の病院と保険業者の関係の厳格化の一端を示した。州で最も有力な病院がいかに高い返還レートを保つかを暴露し、州が保険料を調節できるかを探求する予定だと発表した。
 2010年度予算で約40億ドルのギャップが出る。健康保険プログラムには今年度は2006年より42%増の5億9500万ドルを支出する予定だという。しかし、約432,000人が保険を獲得し、無保険者はわずか2.6%となり、全国平均の1/6である。
 新たに獲得した人で約60%が公的保険である。マサチューセッツでは健康保険を提供する雇用者の割合も増加している稀な州である。無保険や不充分な保険のために病院に治療費が支払われていなかった分が昨年は約2億5000万ドルに相当し、州政府は実質的な節約となったと考えている。
 1年を通して初めて施行され、予想より登録率が高く、州の予算ギャップに陥った。タバコ税の引き上げや罰金強化などで知事と議会は対応した。
 8億2000万ドルのCommonwealth Care program登録は昨年5月にピークに達してその後は減少した。委員会は様々なオプションを検討しているが、出来高払いシステムは廃止するだろう
 州最大の保険業者ブルークロス&ブルーシールドは最近、年齢、性別、健康状態状態を調整して1人の患者あたり均一料金を医師に支払い、それから治療の高い水準へのボーナス報酬を追加する革新的なモデルを考案した。ブルークロス役員は、新たなプランが、5年間でプレミアの増加を半減し、6月までに契約の15%を占めるだろうと信じると言う。専門家は、支払い習慣における変化が他の費用節減戦略と組み合わされても、医療費増加を十分には抑制できないだろうと主張している。州や連邦政府が実際に医療費支出制限を設ける必要があるだろうと言う。「医療費を実際に制御するには支出を止めるしかない」
 適格者を限定することで公的保険から排除する方法は他の州とは異なりできない。
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マサチューセッツ州 無保険者が1年で半減/米国医療事情
http://kurie.at.webry.info/200806/article_4.html
皆保険により逼迫するマサチューセッツの医療/米国医療事情
http://kurie.at.webry.info/200804/article_9.html
BBC記者が見た米国医療の変革/米国医療事情
http://kurie.at.webry.info/200807/article_6.html
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Massachusetts Faces Costs of Big Health Care Plan
http://www.nytimes.com/2009/03/16/health/policy/16mass.html
By KEVIN SACK
Published: March 15, 2009

BOSTON ― Three years ago, Massachusetts enacted perhaps the boldest state health care experiment in American history, bringing near-universal coverage to the commonwealth with Paul Revere speed.

画像Douglas Healey/Associated Press
Gov. Deval Patrick of Massachusetts hopes to revamp the way public and private insurers reimburse physicians and hospitals.

To make it happen, Democratic lawmakers and Gov. Mitt Romney, a Republican, made an expedient choice, deferring until another day any serious effort to control the state’s runaway health costs.

The day of reckoning has arrived. Threatened first by rapid early enrollment in its new subsidized insurance program and now by a withering economy, the state’s pioneering overhaul has entered a second, more challenging phase.

Thanks to new taxes and fees imposed last year, the health plan’s jittery finances have stabilized for the moment. But government and industry officials agree that the plan will not be sustainable over the next 5 to 10 years if they do not take significant steps to arrest the growth of health spending.

With Washington watching, the state’s leaders are again blazing new trails. Both Gov. Deval Patrick, Mr. Romney’s Democratic successor, and a high-level state commission have set out to revamp the way public and private insurers reimburse physicians and hospitals.

They want a new payment method that rewards prevention and the effective control of chronic disease, instead of the current system, which pays according to the quantity of care provided. By late spring, the commission is expected to recommend such a system to the legislature.

If Massachusetts becomes the first state to make this conversion, health policy experts argue that it would be as audacious an achievement as universal coverage. The state faces several hurdles, including securing federal permission to impose the changes on Medicaid, a shared state and federal program, and more unusually on Medicare, which is financed entirely by Washington.

Those who led the 2006 effort said it would not have been feasible to enact universal coverage if the legislation had required heavy cost controls. The very stakeholders who were coaxed into the tent ― doctors, hospitals, insurers and consumer groups ― would probably have been driven into opposition by efforts to reduce their revenues and constrain their medical practices, they said.

Now those stakeholders and the state government have a huge investment to protect. But the task of cost-cutting remains difficult in a state with a long tradition of heavy spending on health care. Massachusetts has more doctors per capita than any state, Boston is home to some of the country’s most expensive academic medical centers, and a new state law requires comprehensive benefits like prescription drug and mental health coverage.

Alan Sager, a professor of health policy at Boston University, has calculated that health spending per person in Massachusetts increased faster than the national average in seven of the last eight years. Furthermore, he said, the gap has grown exponentially, with Massachusetts now spending about a third more per person, up from 23 percent in 1980.

“Just as this may have been the easiest place to do coverage, it may be the most difficult place to do cost control,” said Jonathan Gruber, a health economist at the Massachusetts Institute of Technology.

But Mr. Patrick has shown signs of playing tough with the state’s hospitals and insurers. Responding in January to a series in The Boston Globe that exposed how the state’s most influential hospitals negotiate high reimbursement rates, Mr. Patrick announced that he would explore whether the state could regulate insurance premiums.

“Frankly, it’s very hard for the average consumer, or frankly the average governor, to understand how some of these companies can have the margins they do and the annual increases in premiums that they do,” Mr. Patrick said in an interview. “At some level, you’ve just got to say, ‘Look, that’s just not acceptable, and more to the point, it’s not sustainable.’ ”

The threat seems to have been heard. Insurers seeking to participate in the state’s subsidized insurance program, Commonwealth Care, recently submitted bids so low that officials announced last week that they would keep premiums flat in the coming year. That may provide cover for the program as the state seeks ways to fill a nearly $4 billion gap in its 2010 budget.

The state expects to spend $595 million more on its health insurance programs this year than in 2006, a 42 percent increase. But about 432,000 people have gained coverage, leaving only 2.6 percent of the population without insurance, according to a recent state survey. At only one-sixth the national average, that is by far the lowest rate in any state.

Massachusetts achieved its high coverage rates by mandating in its landmark law that almost every resident have health insurance, and that all but the smallest businesses make some contribution toward their employees’ costs. Those who do not enroll but are deemed able to afford insurance can be fined up to $1,068 in the 2009 tax year.

To make the mandated insurance affordable, the state subsidizes premiums for those earning up to three times the federal poverty level, or $66,150 for a family of four. Massachusetts already had a law requiring insurers to accept all applicants regardless of their health status.

Although nearly 60 percent of the newly insured are covered by public programs, Massachusetts also seems to be a rare state where the percentage of employers offering health benefits is actually growing. And the state government has realized substantial savings, worth about $250 million last year, from lower payments to hospitals for uncompensated care for the uninsured and underinsured.

In its first full year of operation, Commonwealth Care drew higher enrollment than anticipated, and the state found itself facing an inaugural budget gap. Mr. Patrick and the legislature filled it by assessing insurers and hospitals, raising the penalty on noncompliant businesses, increasing premiums and co-payments for consumers, and raising the state tobacco tax.

The fear was that such tree-shaking would become an annual ritual. But enrollment in the $820 million Commonwealth Care program peaked last May and then declined before hitting a plateau.

Some modest provisions to control costs were included in the original health care bill, including a merger of the small group and individual insurance markets and new spending on electronic record-keeping and hospital infection control.

More efforts were made last year in legislation that provided incentives for doctors to practice primary care, required uniform billing procedures among providers, toughened the state’s regulation of new hospital construction, and established the payment reform commission.

The commission is looking at various options, but all would do away with the fee-for-service system, which provides perverse incentives by paying physicians and hospitals for each patient visit. The changes under consideration include reimbursing for episodes of care rather than individual visits and bundling payments to groups of providers who would together take responsibility for a patient’s health.

Blue Cross and Blue Shield of Massachusetts, the state’s largest insurer, recently devised an innovative model that pays doctors a flat fee per patient, with adjustments for age, gender and health status, and then adds bonus payments for high standards of care.

Blue Cross officials say they believe that the new plans can cut the growth of premiums in half over five years and expect them to account for 15 percent of their business by June. “We’re very committed to this path because we feel it’s the only credible place to go,” said Cleve L. Killingsworth, the company’s chairman.

Some health policy experts argue that changes in payment practices will not be enough to slow the growth in spending, even when combined with other cost-cutting strategies. To truly change course, they say, the state and federal governments may need to place actual limits on health spending, which could lead to rationing of care.

“Really controlling costs requires just stopping spending,” said Stuart H. Altman, a professor of health policy at Brandeis University.

Because Massachusetts now requires its residents to be insured, it cannot fall back on the strategy used by other states in hard times ― to simply remove people from the public insurance rolls by restricting eligibility.

“It forces us to look in the mirror and say, ‘What do we do about health care spending?’ ” said Jon M. Kingsdale, executive director of the agency that administers Commonwealth Care. “And the reason that’s so challenging is that it means limiting resources for people doing really good stuff.

“It’s not like the fat sits out here easily identified and you just slice it off. It’s marbled throughout the meat.”

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高騰する医療費問題に直面するマサチューセッツ/米国医療事情 医師の一分/BIGLOBEウェブリブログ
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