Finding common ground in health care reform: How to replace the ACA
January 11, 2017
We are at a Rubicon moment in the battleground of health care reform. The ACA has expanded insurance coverage to millions of Americans, but it has not altered the basic flaws inherent to our health care delivery system. Now with its elimination hovering over us, we have an opportunity to come together and enact changes in medical care that are universally endorsed and can evade partisan bickering. Can conservatives develop a free market health care system that also achieves the patient-centered goals of progressives? Can insurance companies and hospitals help promote a system that enables them to reduce waste and improve profit at the same time patients have more choice and access to better care? In fact, the answers are yes. A free market health care system is also a progressive health care system. A system that helps insurance companies thrive is also one that most benefits patients. There is no reason that health care reform needs to be contentious and partisan. The fact is that most of us agree on what needs to be done to replace the ACA and create something much better.
No matter one’s political slant, there are several objectives to which every reformer can agree. First, with the knowledge that we squander almost a trillion dollars a year (twice the entire military budget) in wasteful medical spending, successful reform must reduce low-value/high-cost medical expenditures and promote care that is efficient and effective. Most patients seek the same goal. Second, in what conservatives call a free-market approach, and what progressives call a patient-centered approach, reformers must empower patients to be able to make rational medical decisions that are most beneficial for them. This will increase patient satisfaction, decrease over-treatment, and cut cost dramatically. Both goals require fundamental shifts in how doctors and facilities are paid and graded, and also require increased transparency of medical cost and risk/benefit information, but are easy to obtain with some very simple tweaks to our current system:
Curtail our regulatory environment: While Republicans often seize the mantle of owning an anti-regulation posture, it is actually more progressive physicians with whom I work who are most passionate about rationalizing health care regulation. From the scrolls of nursing home rules that transform what should be peaceful sanctuaries at the end of life to expensive and aggressive mini-hospitals; to HIPAA regulations that prevent doctors and patients from having a consensual conversation by email; to Electronic Medical Record requirements that earned doctors like me a 3% cut in pay this year; to quality indicators that force doctors to push unnecessary and often harmful tests/drugs/procedures on patients lest they have significant cuts in reimbursement, health care regulations hinder rational and cost-effective treatments. They add to unnecessary cost while hindering patient care, the doctor-patient relationship, and patient autonomy. Re-writing regulations to make them simpler and more conducive to rational patient-centric care is something with which all reformers can agree.
Enhance patient choice: When patients can make choices that are best for their own health care needs, they typically choose a sensible path. This is how the free market works. But currently patients have little access to accurate and comprehensible medical data. In a related blog, I discuss how a simple visual decision aide called a BRCT can transform the ability of patients and doctors to understand and discuss medical information. We need to implore the news media, physicians, drug companies, and national data bases to present medical information in a similar format, something that can be incentivized in many ways. Patients cannot partake in a free market health care system unless they understand the risks and benefits of their decisions. Similarly, patients need the ability to make genuine choices, unencumbered by the rules and financial disincentives that prevent them from doing so now. If, after discussing the data with their primary care physicians, patients decide not to get a cardiac stent and instead to work on smoking cessation, an exercise program with a trainer, and a diet that is both healthy and which they can afford, then they have to have just as much access to the latter choice (which is the most beneficial and cost-effective) as they do to the former. Now insurance will pay $30,000+ for a stent even when it is not helpful, but it will not pay for preventive health care. Similarly, studies show that in many circumstances home care is more effective are far less expensive than hospital care especially for those who are elderly, have dementia, and suffer from many chronic illnesses. I discuss this at length in my book, and a recent article highlights the potential efficacy of home care. However, although many patients prefer to be treated at home, they do not have that choice under current insurance rules. By giving patients knowledge and options so they can steer their own health care under the guidance of physicians, we will achieve a lower-cost, higher-value system, which is what conservative and liberal reformers both seek.
Pay doctors based on value: There is nothing more antithetical to a progressive, free-market health care system than our current payment model. Triggered by the recommendations of a non-transparent specialist-dominated committee in the AMA, Medicare and other insurers pay doctors more to perform tests and procedures than to work with their patients to solve complex medical problems and provide sensible guidance and treatment. When doctors are paid exorbitant fees to place a stent in someone’s artery, to conduct annual heart tests, to clean cartilage out of a knee, and to utilize intravenous treatments even if such interventions provide little to no value over less expensive and more effective alternatives, then we are incentivizing our medical providers to endorse low value care. Should not the system pay doctors more to think and help guide their patients down sensible medical paths than it pays them to perform technical tasks that are of lower value? Only then can we achieve the high-value health care system that all reformers strive to create. Our payment system must be changed to reflect what is needed in a free market environment, so that doctors are paid to enable patients to make rational choices and not be financially hurt for doing so.
A truly high-value health care delivery system would rely on the bulwark of primary care to help achieve effective and low-cost care. Currently only 20% of medical students enter primary care fields, since specialists earn often hundreds of thousands of dollars more a year than their primary care colleagues, a gap that exists because of our payment system. By altering physician compensation as noted above, it is likely that primary care will again become a credible force of change in the health care landscape. Why is that important? Because studies show that in areas of the country with a higher percentage of primary care doctors compared to specialists, costs decrease, outcomes improve, and patient satisfaction is enhanced. We need more primary care doctors, again something to which both parties give lip service, and we need them to steer our health care system. As I discuss in my book, a few changes in Medicare can facilitate this process, and primary care will no longer be relegated to a lower rung on the health care continuum. Also, something that is in line with Paul Ryan’s focus on health saving accounts and with progressive ideas about improved patient access to thoughtful doctors, we could consider more of a concierge approach to health care, whereby insurance allows patients to purchase access to primary care based on an annual fee rather than the fee-for-service model in which we now exist. Steve Schimpff discusses this in a recent article in Medical Economics, and it offers a very viable free-market approach to medical quality that is built on primary care.
Expand insurance coverage: We cannot simply ignore the fact that the ACA’s expansion of health care coverage benefited everyone in the health care marketplace: patients, insurers, hospitals, physicians, and the American economy. The expansion of Medicaid not only helped the very poor, but also the working middle class and the large numbers of elderly who live in nursing homes. The ability of lower income people to purchase health insurance enables insurers to lower rates and accept clients with pre-existing conditions, enables hospitals to cut cost and save Medicare money, and gives physicians a larger pool of paying customers. If we scrap the ACA and do not find another way to provide health insurance to a vast majority of Americans, then much of what we discussed above cannot occur. Expanded coverage is necessary for the free market, and is crucial for the realization of progressive ideals.
As I argue in a recent RealClearHealth article, the ACA did not lead to increased health insurance premiums, but by not fixing the dysfunction of our health care system, the ACA did nothing to curb the excess that did precipitate cost escalation. It is time that Democrats, Republicans, doctors, hospitals, patients, and insurers come together to provide sensible health care for all Americans. It is not difficult to achieve, as long as we do not allow an artificial partisan divide stop us in our tracks.