With an eye on rising costs, the health care industry today is looking for new ways to contain spending while improving patient care.
It’s a monumental goal, one that insurers and care providers, prodded by landmark health care laws, are trying to tackle. Dolores L. Mitchell has been doing it for nearly three decades.
For 29 years, Mitchell has led the Group Insurance Commission, or GIC, an obscure but critical state agency that manages health and other benefits for more than 430,000 public employees, retirees, and their families, spending more than $2 billion a year. Mitchell has used the role as a means not just for providing good, cost-effective benefits for her members, but also to push for change in how health care is delivered and paid for across the industry.
She was an early champion of changes that upended the status quo — ranking doctors based on how well they managed costs, for example — drawing criticism from powerful interest groups such as the Massachusetts Medical Society but all the while commanding their respect.
Mitchell is rare among government appointees; she has kept a high-ranking job under seven governors, Republican and Democratic.
“It’s a big item in the budget, and governors in both parties want that place run right,” said former Massachusetts governor Michael S. Dukakis, who suggested Mitchell for the post. “They didn’t want to mess around. She’s run the place right.”
Mitchell, 86, will retire next month. In the downtown Boston office where she has spent her days since 1987, she reflected on the principles she has tried to follow throughout her career. One of them, she said with a smile: “It is better to be feared than loved.”
That kind of brazen confidence has been crucial to Mitchell’s mission: providing good benefits and improving health care, all while containing costs.
A decade ago, before “big data” came into vogue, the Group Insurance Commission sifted through mountains of claims data and began ranking physicians according to how well they scored on certain quality and cost-efficiency measures. They assigned lower co-pays for physicians who performed well under those measures, and higher co-pays for the others.
The idea was to encourage patients to choose doctors with lower co-pays, thus pushing other doctors to improve. But it was so controversial that it drew protests and a lawsuit from the Massachusetts Medical Society, which objected to the formula used for the rankings and didn’t want individual doctors singled out for their performance.
The two sides ultimately settled their dispute, after the Group Insurance Commission agreed to share more data with doctors. A 2014 Harvard study found the effort had mixed success. Lower co-pays had little effect on patients who already had relationships with their doctors, but they did encourage patients choosing doctors for the first time to select higher-ranked physicians.
The Mass. Medical Society still has concerns about the program, said Corinne Broderick, its executive vice president, but it has maintained a good relationship with the GIC.
“Dolores has always been willing to talk and meet,” she said, “no matter if we agreed upon the issues or not.”
Mitchell is perhaps an unlikely health care reformer. An Ohio native, she first came to Massachusetts to get a doctorate in government studies at Harvard but eventually decided she didn’t want to become an academic. She lobbied for advocacy groups, worked in the first Dukakis administration, and ran a school for secretaries before running the GIC. When the commission hired her in 1987, she said, she didn’t know “diddly squat” about health care. But she learned quickly.
She has not been afraid to speak her mind — she openly admits to “bullying” insurers — and does not seem to worry about wounding egos at the state’s most powerful health care institutions. She calls out hospitals and drug companies for their high prices, even when sharing a stage with them during speaking events.
“It’s very difficult to convince these people who are constantly being told what a great job they’re doing that they could do better, and do better at less cost. That’s a very hard sell,” Mitchell said. “I would liken it to pushing molasses uphill in January.”
Mitchell also pushed insurers, using the sheer size of the Group Insurance Commission — the biggest health care purchaser in the state — to get her way. She has required insurers who offer plans through the GIC to build and expand contracts with health care providers that set spending budgets and tie payments to quality scores; that effort began five years ago, before such payment systems started to become commonplace.
“She really was effective in getting us to change faster than we would have otherwise,” said Eric H. Schultz, the chief executive of Harvard Pilgrim Health Care. “She was motivated to use the force of the GIC to really bring about change. She wanted to make a difference.”
Mitchell, whose agency is funded by taxpayers, has taken a variety of steps to contain costs. She eliminated health plans that became too expensive. She required health insurers to create plans that lower premiums by limiting the doctors and hospitals in their networks.
Last year, Mitchell’s team redesigned plans from Harvard Pilgrim and Tufts Health Plan to keep premium increases to an average of 5.7 percent, instead of the 9.5 percent insurers wanted. Members now have to choose primary care physicians and obtain referrals before visiting specialists to limit their out-of-pocket costs.
Governor Charlie Baker worked with Mitchell when he served in former governor William Weld’s administration and later as chief executive of Harvard Pilgrim.
He said Mitchell found “the secret sauce” to survive through seven administrations by focusing on her members, doing her homework, and always speaking her mind.
“She has always recognized that in health care, you’ve got to be willing to change and think differently,” Baker said.
Those changes have not always been welcome. Some have shifted more health care costs to employees, a strategy followed by many other employers. The GIC increased deductibles last year to $300 from $250 for individuals, and $900 from $750 for families.
Such changes insulate the state from costs but are a growing burden on state employees, said Dawn Davis, a counselor and supervisor at the Massachusetts Rehabilitation Commission. Davis said she’s paying hundreds of dollars a year more out of pocket for medications, blood tests, and doctor visits than she was a few years ago.
“One of the things that drew me to the state was the benefit package,” Davis said. “The health care benefits were very good and were reasonable in terms of costs. They’ve gone up over the years. That’s hard.”
Mitchell has seen many iterations of health care reform over her career. But now, she said, the pressure to contain health care costs seems to be stronger than it’s ever been.
That intractable challenge has kept Mitchell so busy that she has stayed in her job long after most people retire. But now, she said, she wants to leave on her own terms, before her health or strength decline, and people start “muttering behind her back” that it’s time for her to go.
“Health care has been constantly challenging, stimulating, interesting, frustrating, maddening,” she said. “Where are you going to find something else to do that has all of those characteristics?”