{"id":440135,"date":"2024-09-18T05:30:00","date_gmt":"2024-09-18T12:30:00","guid":{"rendered":"https:\/\/calmatters.org\/?p=440135"},"modified":"2024-09-18T15:04:16","modified_gmt":"2024-09-18T22:04:16","slug":"healthcare-cost-cap","status":"publish","type":"post","link":"https:\/\/calmatters.org\/_zh\/health\/2024\/09\/healthcare-cost-cap\/","title":{"rendered":"\u52a0\u5dde\u7684\u533b\u7597\u8d39\u7528\u4e0a\u9650\u662f\u5168\u7f8e\u6700\u4e25\u683c\u7684\u3002\u4f46\u60a3\u8005\u4f1a\u6ce8\u610f\u5230\u5417\uff1f"},"content":{"rendered":"
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California’s new cap on health care cost increases is regarded as the most aggressive in the nation. It includes potential fines against companies that exceed the limit.<\/p>\n\t\t\t\t\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n\t\t\n

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Vickie Villegas had to pay $3,000 out-of-pocket every time she was treated for multiple sclerosis, a disease that attacks the central nervous system. Her doctor recommended she get treatments twice a year to keep the disease from worsening, but she couldn\u2019t afford it, the Pasadena-area resident said.<\/p>\n\n\n\n

\u201cI just couldn\u2019t keep up,\u201d Villegas said. Her disease progressed, and she lost use of her left hand.<\/p>\n\n\n\n

When an infection landed Estevan Rodriguez-Hernandez in the hospital for a week in 2020, his bill totaled more than $167,000. After insurance, Rodriguez-Hernandez owed $5,600, but the COVID-19 pandemic prevented him from working.<\/p>\n\n\n\n

\u201cI remember seeing that bill, and I talked to my mom and was like \u2018I’m gonna go bankrupt,\u2019\u201d Rodriguez-Hernandez, who lives near Monterey, said.<\/p>\n\n\n\n

Villegas\u2019 and Rodrigeuz-Hernandez\u2019 stories are all too common in California, where the average cost of health care is the third highest in the nation<\/a>.<\/p>\n\n\n\n

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Vickie Villegas sits with Dr. Lise Phan, while she uses an EMG machine to check Villega’s nerve muscle stimulation in Pasadena on April 24, 2024. Photos by Brandon Tauszik for CalMatters<\/figcaption><\/figure>\n\n\n\n

California is moving to address their needs with a new cap on health care cost increases<\/a> that experts consider to be the most aggressive in the nation. The cap does not mean that bills that patients such as Villegas and  Rodrigeuz-Hernandez are charged would go down. It aims to limit how much consumers pay over time by first constraining how much the health care industry spends. Research suggests up to 30% of health spending is wasted<\/a> on overtreatment and administrative inefficiencies.<\/p>\n\n\n\n

By 2029, California hospitals, doctors and insurers cannot increase spending by more than 3% annually. This means they will need to find ways to cut costs to keep from exceeding the target. If they do exceed it, state regulators with the Office of Health Care Affordability have the authority to levy fines and other penalties \u201ccommensurate with the failure of the health care entity to meet the target,\u201d according to state law. The law also has guardrails preventing health care entities from saving money by reducing services.<\/p>\n\n\n\n

The cap, which was set in April, is modeled on the work of eight other states, including Massachusetts, that have tried to curtail runaway health spending. California went further by allowing the state to compel public testimony from health care facilities, require performance improvement plans and impose unlimited financial penalties<\/a> on businesses that exceed the cost cap.<\/p>\n\n\n\n

Massachusetts, by contrast, has ordered just one performance improvement plan<\/a> and it has not levied a fine on any \u536b\u751f\u4fdd\u5065<\/a> provider since it created its own cost control target in 2012. It also has the ability to fine facilities that spend too much, but regulators there say penalties are too small to be meaningful. Health insurance premiums there have climbed 43%, outpacing wage growth over nine years.<\/p>\n\n\n\n

\u201cWe felt like you need a stick. You need something to say \u2018We\u2019re serious. We\u2019re going to set these targets, and you\u2019re going to meet them,\u2019\u201d said Assemblymember Jim Wood<\/a>, a Democrat from Ukiah who wrote the law that created California\u2019s affordability board and spending cap.<\/p>\n\n\n\n

State officials say the tougher approach could help patients see real savings. Last month, the Office of Health Care Affordability met in Monterey County, one of the most expensive health care markets in the state, to discuss affordability challenges.<\/p>\n\n\n\n

\u201cWhat happens in Monterey has ripples,\u201d Dr. Mark Ghaly<\/a>, California\u2019s outgoing secretary of Health and Human Services, said at the meeting where board members discussed regulatory options for addressing market failures.<\/p>\n\n\n\n

The state\u2019s hospital and doctors lobbies opposed the cost control cap, saying it was unreasonable given inflation spikes over the past two years. They pushed for a higher benchmark, but the board held to 3.5% next year, which would ramp down to 3% by 2029. That number, board members said, reflects the average growth of median household income over the past 20 years, tying it directly to the consumer experience.<\/p>\n\n\n\n

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California Health and Human Services Secretary Dr. Mark Ghaly speaks during a press conference in Fontana on Feb. 17, 2022. He leads a state board charged with bringing down California health care costs. Photo by Alisha Jucevic for CalMatters<\/figcaption><\/figure>\n\n\n\n

California Medical Association President Dr. Tanya Spirtos wrote in a letter to the board that \u201cmost physician practices and health care entities\u201d will not meet the target, and that patient care would suffer.<\/p>\n\n\n\n

Rodriguez-Hernandez, who faced the steep medical bill from his infection, spoke to the board last month and urged it to be tough with the industry. He works part time as a bartender in Monterey and part time as a community health advocate. He blew through his savings to pay rent and relied on a food bank for a time to cut costs after his hospital stay. It took him two years to pay off his medical bill. Today, he doesn\u2019t have insurance.<\/p>\n\n\n\n

Is it working in other states?<\/h3>\n\n\n\n

Much like California, Massachusetts is known for its world-class health care system bolstered by academic research centers. In 2012 it was also one of the most expensive places in the country to get care. Health advocates and lawmakers wanted to do something to make it more affordable.<\/p>\n\n\n\n

\u201cIt can’t be that health care just has a blank check to grow as fast as it wants because we’re all paying for that, and the result is that more people then can’t afford to get the care that they need,\u201d said David Seltz, executive director of the Massachusetts Health Policy Commission.<\/p>\n\n\n\n

Lawmakers there came up with a strategy to rein in costs. They established the Health Policy Commission, which would set a growth target for the industry and publicize its progress. Initially it set a target of 3.6% annual growth rate. In the first five years, commercial spending on health care was estimated to be $7 billion less than it would have been without the regulations, according to an analysis by the Commonwealth Fund<\/a>. Other states modeled their own health care cost control measures on the one in Massachusetts.<\/p>\n\n\n\n

\u201cThat sentinel effect, that watchdog effect I do believe has changed market behavior,\u201d Seltz said. \u201cIs that enough? No.\u201d<\/p>\n\n\n\n

Consumers are still experiencing unaffordable cost increases, said Alex Sheff, senior director of policy and government relations at Health Care For All Massachusetts, a consumer advocacy organization.<\/p>\n\n\n\t\n\t\t

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‘A market failure’: High prices at Monterey County hospitals drive away many insured Californians<\/a><\/h3>\t\t\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\tby<\/span> Kristen Hwang<\/a><\/span>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t<\/article>\n\n\t\t\t\t<\/div>\n\t\t\n\t<\/div>\n\t\n\n\n

The most recent annual report from the Health Policy Commission<\/a> reveals spending on private health insurance outpaced general inflation and wage growth in 2021. For a family of four, out-of-pocket cost of deductibles, copays and premiums averaged $25,000. Nearly 43% of Massachusetts residents with private insurance are enrolled in high-deductible health plans, more than double the proportion enrolled 10 years ago when the state first started tackling costs.<\/p>\n\n\n\n

Increasing prices, rather than greater health care usage, are the primary driver of spending increases, according to the report. Since 2017, total health care expenditures per capita have regularly exceeded the benchmark set by the state commission.<\/p>\n\n\n\n

\u201cWhen you see premiums continuing to grow at a faster rate and often at the same time out of pocket costs are going up\u2026it suggests that consumers are not benefiting from all of the savings that the benchmark might be creating,\u201d Sheff said.<\/p>\n\n\n\n

Massachusetts needs more regulatory oversight and stricter penalties, Sheff said. Only one hospital has been reprimanded<\/a> for excessive spending in the commission\u2019s 12-year history, and the maximum fine that can be levied is $500,000, an amount Seltz characterized as \u201cnot a significant deterrent given the size and scale of these organizations.\u201d<\/p>\n\n\n\n

California, they say, has set itself up for more success in that regard.<\/p>\n\n\n\n