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Health Reform – Cover More People By Containing Cost

Here’s a very brief quiz about the newest healthcare reform battle about to be waged:

Question:  What do you get when we add more uninsured people to an already costly and inefficient system?

Answer: A MORE costly and inefficient system!

This quiz was not meant to be humorous, nor is it. But if you think we are upset with our healthcare costs today, just wait for what may come next.

As in 2009-2010, similar contentious debates are being made on how to expand and pay for American’s health coverage. We now live in a never-ending polarized environment. Every day we learn about another new plan to rewrite what health insurance should look like in this country. Policy wonks are kept perpetually employed through this process – a really nice form of job security.

So, will we ever see breakthrough policy changes covering more Americans (beyond Obamacare) that will enhance our health (and productivity) at a more affordable cost? Without any doubt, it depends on the political will of both parties. Unfortunately, in the healthcare arena, good policy may not be good politics. In other words, what is best for addressing the core issues and problems of healthcare may not be best for sustaining a political career during the next election cycle. 

If we stay fixated on tying one-fifth of our economy to two-to-four-year election whims, we are doomed to repeat the cycle of not adequately addressing the core problems in our healthcare ‘system,’ which is, primarily, controlling costs. The premise of Obamacare was more about focusing on access first, while neglecting to address cost. 

By the end of 2017, our country is projected to spend about $3.7 trillion in healthcare, which will be 15 percent higher than what we spent in 2015 ($3.2 trillion). To put this into greater perspective, what our country spent on healthcare in 2015 exceeded the gross domestic products of all but four nations. Ironically, so much political capital is exhausted on three essential questions that do not address the root causes of cost:

  1. Who should be covered?
  2. Who should pay for this coverage?
  3. How much should they pay for this coverage?

Many agree that it is good policy to cover more Americans, which will have a positive impact on achieving a healthier population – regardless of demographic differences (age, race, income, location, etc.).

But, as we continue dividing a ‘bloated’ pie laden with sizeable waste between public and private payers, and provoking enraged differences between political parties and citizens, it will be equally logical to address the fundamental causes that make this pie bloated in the first place. 

‘Replacing’ or ‘reforming’ portions of Obamacare should also come with a clear political consensus on eliminating waste and developing performance measures that will provide sufficient feedback on just how well our bloated system is progressing (or not) when providing that care. On a per capita basis, America is already paying a grossly higher amount for healthcare when compared to all other industrialized countries in the world – and some of these countries have universal coverage for their population. One can quite successfully argue that our country has enough money in the current system to cover the entire population. What we lack is the political will to find prudent ways to reapportion our limited financial resources so that it is strategically used more efficiently to also address the social determinants of health. Policymakers are lobbied hard by key industry stakeholders who stand to lose their slice of the bloated ‘entitlement’ pie.

The upcoming debate should begin on what is universally agreeable, but unfortunately, most often ignored. The care provided in this country is woefully underperforming when compared to the cost of this care. This is primarily due to little transparency on price and care outcomes. ‘Value-based care’ – an often over-used phrase – begins with complete transparency in what we pay and receive.

Think about it.  If you or a family member has surgery in a hospital, do you really know the true cost BEFORE the elective surgery takes place? I’m not talking about ‘estimated’ cost, but rather, ‘actual’ cost. (One primary example of how surgery prices can be transparent is found at Surgery Center of Oklahoma.) Then, perhaps three-to-six months following surgery, are you queried by that hospital (or their agent) about how you or a family member is doing after that surgery?  This information is so vital to collect because it will eventually allow for future healthcare delivery improvements.

Who tracks medical outcomes?

Who tracks our medical outcomes on a national, regional or state level? By logic, you may be led to believe that this is being handled. But, despite the great activity seemingly generated by providers and their paid agents, this simply is not happening in most places. For example, the CMS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is sent to a random sample of adult patients in the period of forty-eight hours to six weeks following discharge, but this patient-reported experience addresses hospital performance measures while the patient was in the hospital, not the outcomes experienced by the patient sometime later. The national experiment of paying hospitals to coax better outcomes has been a mixed-bag to date. According to national experts, Hospital Value-Based Purchasing (VSP) have been discouraging.

Transparency will sometimes be mentioned during reform – but tragically, it somehow becomes a casualty during the political process. The inconvenient truth is that full transparency in pricing and medical outcomes may not be in the best interest of many healthcare organizations because obfuscation is still considered to be a ‘competitive advantage.’ In healthcare, the product should not be the PRICING of the care, but rather, the CARE itself. When policy is being made, lobbying participants will usually find a seat at the table, nudging out the much larger but generally diffused public. Any public transparency initiatives soon morph to opaqueness. The key, therefore, is to have good policy also become good politics.

No doubt, some progress is being made in the delivery and payment of healthcare, but much work remains.

Perhaps Yogi Berra phrased it best: “It’s like déjà vu all over again.”

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