By Edie Sonn

Captain Renault in “Casablanca” was “shocked – shocked!” to discover there was gambling taking place in Rick’s Café. Of course, he wasn’t shocked at all; in fact, he uttered that line as he was being handed a pile of money by a croupier. That brief encounter brilliantly encapsulated a cynical culture in which everyone was on the take, yet all pretended they weren’t.

Edie Sonn

I’m reminded of this line as I listen to the increasingly loud clamor over the cost of health care in this country, and more recently in the resort towns of Colorado. From Steven Brill’s “Bitter Pill” article in Time magazine about the price of hospital care to the outcry over variations in health care premiums in different parts of our state suddenly, everyone is talking about things that folks in the health care industry have known, but done little about, for years.

We’ve pointed the finger at each other when the time came to solve these issues. I say “we” because I spent many years in communications and public affairs working on behalf of health plans, hospitals, pharmaceutical companies, ambulance providers and physicians – so I did a lot of finger-pointing myself.

Here’s how one circle of blame goes, on the issue of medical technology:

• Health plans point to hospitals as one culprit for high premiums, and highlight cost drivers such as hospitals’ investment in robotic surgery tools that may not improve outcomes.
• Hospitals point to the physicians who insist on having the latest whiz-bang device or else won’t affiliate with that hospital.
• Physicians point to the health plans for not paying for evidence-based care. If the plans did that, then they wouldn’t reimburse the hospitals for robot-assisted surgeries when the data don’t show outcomes are appreciably better.
• And all of them point to the wily device salesmen who prey on the hapless physicians and hospital administrators, and the patients who want the latest and greatest technology they just read about on the Internet.

Of course, this is just one example. We could talk about the blame game of pharmaceuticals and prescribing, or diagnostic tests, or plenty of other cost drivers. But the theme is the same: it’s always the other guy’s fault. Yet everyone in that circle of blame is actually doing pretty well. And they are all “shocked, shocked” that anyone would question their contribution to spiraling prices.

Now, though, those questions are getting louder and more frequent. The Brill article garnered more attention than any of the scores of similar stories over the last couple of decades – maybe because he included so many examples, and the stonewalling he got from some of the pharmaceutical companies and hospitals was so egregious (or maybe because people just figured that anything to which Time devotes a 42-page special report must be worth paying attention to).

More recently, and closer to home, there’s been a lot of discussion – and anger – about variations in the cost of health insurance in different parts of the state. Once the Connect for Health Colorado marketplace went live, people were able to see more readily than ever before that health insurance costs more in most resort counties than in most urban counties. And, to quote another movie, they are mad as hell and aren’t gonna take it anymore.

And that is what may be bringing us to the tipping point. It’s not just policy wonks saying things have to change; it’s real people. People who pay the bills. Citizens. Taxpayers. Constituents.

You can see the impact already. Colorado Commissioner of Insurance Marguerite Salazar is convening a group to study health care costs; State Sen. Irene Aguilar is sponsoring legislation to establish a cost containment commission that will build on the work of the commissioner’s study group, analyzing cost drivers and recommending policy changes to address them.

These are important initiatives, and I applaud these leaders for launching them. To really succeed in changing the dynamic, these initiatives must explore every element of the system: health plans, hospitals, docs, pharmaceuticals, equipment and devices, and yes, patient behavior too. They must have the freedom to perform the kind of root cause analysis that takes place in hospitals every day when something goes wrong: ask “why?” again and again and again and again and again, digging deep under the excuses and easy answers until the real explanations are exposed. Everyone who’s been in on the game will stand to lose something. But Colorado’s patients will gain.

Edie Sonn is CIVHC’s interim CEO and vice president of strategic initiatives. Contact her at [email protected]