NPR took a look the other day at the aftermath of Deval Patrick's controversial decision two years ago to wield a tool few governors (outside of the northeast) can and do: health insurance rate review. Over the past few years, most of the New England states (e.g. Maine, Rhode Island, Connecticut) have rejected or pared back premium increases requested by insurers who couldn't justify them, but none on quite so grand a scale as Massachusetts in 2010. These stats are correct. The average insurance premium in Massachusetts in the 2nd quarter of 2012 will be rising 1.8 percent, down from 16.3 percent in the 2nd quarter of 2010. The point of interest here (to me) is that it illuminates a theme I've harped on again and again: the importance of the balance--or struggle--between insurers and providers to the cost and price issue. In Massachusetts, as in a number of states, it's not hard to believe that the balance tips in favor of certain providers. Last year the Coakley report on health care trends in Massachusetts highlighted the fact that despite large variations in what different providers are being paid--"the difference in payments made to the lowest paid versus highest paid hospital in each major health insurer’s network exceeds 170%, and for two health insurers, exceeds 300%"--the data suggests "there is no correlation between hospital price and quality" in the state. In that case, the question becomes how to give insurers the leverage they need to avoid exploitative reimbursement rates and increases from dominant providers, or how to light the fire under their asses to wield the leverage they already have. Two years ago many liberals thought a "robust" public health insurance option (with reimbursement rates initially pegged to Medicare's, plus five percent) was the best way to do this, other folks think some form of all-payer rate setting is the best way to approach the problem. In Massachusetts, Patrick went about it by denying insurer premium increases. That's the significance of the quote from the president of BCBS, the state's largest health insurer: "It sent a message to the entire health care community and the business community that we had to change." They might be a little hasty in giving the global payments too much credit; the Alternative Quality Contract BCBS is testing out isn't really intended to be evaluated before its first five years of operation are up and we're not quite there yet. But the fact that insurers in the state are standing up to providers and stepping up to demand value for their dollar is a promising sign. Still, the article is right in pointing out that they've still got a ways to go toward fixing the payment and delivery dysfunctions in their system.