Health Affairs ForefrontFollowing The ACA
Beyond ‘Repeal and Replace’: Physicians Renew The Call For Delivery System Improvement
The last few months have been an anxious time in health care policy with calls to repeal, replace, repair, and delay repeal of the Affordable Care Act (ACA). Daily, elected officials face angry constituents fearful of losing their coverage. What is clear is that voters want affordable, convenient, technologically enabled, high-quality medical care. We believe such care is possible, but only by leveraging the "doctor-patient" relationship and transforming how medical care is structured, measured, and reimbursed.
We are physicians who have led two of the nation’s highest-performing health care systems: Kaiser Permanente and the Austin Regional Clinic. We base our recommendations on work we have done with other physician leaders of the nation's largest multi-specialty medical groups through the Council of Accountable Physician Practices, where we are chair (Pearl) and vice-chair (Chenven).
Policymakers who are focused predominantly on how to improve the health care system by providing health insurance coverage will fail unless they simultaneously focus on transforming and modifying the delivery system; otherwise, the cost of providing that care will erode any program they create, whether coverage is provided through private insurance, Medicare, Medicaid, or another method. For this reason, we encourage the new Administration and members of Congress to consult and rely on the nation’s physician leaders, in addition to health insurance executives, to help chart the course for American health care in the future.
While there are many different “levers” to pull for delivery system improvement, three are absolutely fundamental to bringing about positive change and enhancing the doctor-patient relationship: As a nation we will need to move rapidly from fee-for-service to value-based reimbursement, and from paper and stand-alone computer systems to comprehensive, integrated, and mobile electronic health records. At the same time, we will need to track quality and patient satisfaction in ways that improve clinical outcomes without overly burdening physicians. We believe that all three of these objectives can be accomplished, and that they need to be central to the approaches and legislation currently being contemplated by policymakers.
A fee-for-service system that rewards doctors and hospitals based on volume, even when the outcomes are sub-optimal, will not cure America's health care quality and cost problems. This type of payment leads to billions of dollars in inappropriate, unnecessary, and often harmful care. We need instead to pay providers for producing health and achieving the best outcomes quickly and safely, the first time a patient is treated.
The public and private sectors both have made strides in shifting health care payments from volume- to value-based. Medicare Advantage and Medicaid managed care programs continue to grow. Public and private payers are currently experimenting with accountable care organizations, capitated approaches, and bundled payments for episodes of care. Regardless of what Congress does relative to the ACA itself, these efforts to transform American health care need to continue. Coupled with quality reporting, the shift to capitation and other forms of prepayment at the delivery system level creates the right incentive for providers to deliver the highest quality care, every time.
We recognize that not all providers are ready to accept full capitation, and that bundled payments, if done well, are an important step in the right direction. However, to make a significant reduction in the cost of health care and improve the health of people, payers must broaden the scope of these programs to include the most common chronic conditions, such as coronary artery disease and diabetes. They must also reward disease prevention and improved patient safety. To accomplish these objectives, we will need scientifically sound research to ensure that the scope of any given payment bundle is concordant with the natural history of the disease, and that it produces high-quality, long-term outcomes.
(As an aside, we note the current controversy about whether or not Medicare’s bundled payment programs should become mandatory. Mandating anything in this country inevitably results in resentment and controversy, and the juice may not be worth the squeeze. We hope regulators will be creative enough to design an incentive-only program that achieves a respectable return-on-investment without the pushback.)
Widespread And Coordinated Use Of Robust Health Information Technology
Under the HITECH Act of 2009, the federal government invested $30 billion in incentives for health care providers to purchase health information technology (HIT), yet different vendors’ systems can’t “speak” to one another. In 2015, 78 percent of office-based physicians had an electronic health record (EHR) system certified by the Office of the National Coordinator for Health Information Technology (ONCHIT). However, in that same year, only 48 percent of office-based physicians could electronically send or receive patient health information with any other provider. In a 2015 report to Congress, ONCHIT expressed concern that, for competitive reasons, some EHR vendors are deliberately making the exchange of health information from one system to another difficult or impossible.
As a result, information about a single patient can be scattered across multiple systems operated by different providers, with no way to bring it all together. This type of fragmentation isn’t tolerated in any other industry, whether banking or travel. People want and deserve the same secure, private, and convenient access to services and information in health care that they have in every other part of their lives.
But HIT must do more than support an EHR that can be shared among providers. It must also allow patients and providers to connect with each other in more efficient and convenient ways, using “e-health” tools, such as secure email messaging and telephone and video visits. Current reimbursement policies, particularly in Medicare, provide a disincentive for providers to use these modalities to provide care to patients without forcing them to miss work and school for office visits.
We urge policymakers to prioritize improvements in the use of HIT in two important ways: First, create an expectation that, within a relatively short period of time, EHR vendors will open their Application Program Interfaces (APIs) so that third-party developers can connect the disparate systems and achieve full interoperability of HIT systems. Second, promote payment policy that allows providers to use and be reimbursed for e-health interactions over the telephone, secure email, or video when medically appropriate and preferred by the patient.
Improved And Harmonized Quality Measurement
Quality measurement and reporting are foundational to value-based payment. We can’t pay for value if we don’t know it when we see it. If we want to simultaneously improve health while lowering cost, it will be essential to determine which patients actually benefit from the care they receive and which do not. And if we want to empower consumers to make better choices in their health care coverage, and select the best for themselves and their families, we need to provide quality information at the level of the delivery system.
There is widespread agreement that the current “system” of quality measurement in this country is extremely problematic. It is fragmented, redundant, and burdensome to providers, and confusing for patients. It must be improved in a number of critical ways. First, we must do a better job of identifying the highest-value measures, moving more quickly to measuring outcomes of care, rather than processes, when possible. To do so will certainly require robust risk-adjustment mechanisms to account for the many clinical, demographic, and socio-economic differences among providers’ patient populations.
Second, outcomes measures must be organized around things that patients care about, such as how quickly they can resume normal activities and return to work following surgery. And we will need to include all care settings, including hospitals, surgical centers, and medical offices.
Third, payers, both private and public, will need to work together to standardize quality measures amongst themselves and limit the total number to avoid overwhelming and unfairly burdening doctors and hospitals. Today, health care providers must produce hundreds, if not thousands, of largely duplicative measures for payers that may address similar issues, using slightly different methodologies. This is a waste of health care resources that could be better spent on care improvement and delivery.
In recent years, several multi-stakeholder groups have issued reports recommending a drastic winnowing down of existing measures. For instance, the public/private Core Quality Measures Collaborative has proposed seven domains (with dozens of measures in each). These efforts are important, but we must go further. A set of two dozen or so measures in a limited number of domains—including prevention and chronic disease management—would allow for meaningful quality measurement.
These three tenets of delivery system improvement—value-based payment, health information technology, and quality measurement—are linked in so many ways. At a high level, value-based payment provides financial support for physicians and hospitals to invest in quality measurement/improvement and information technology. In turn, information technology and quality measurement help us recognize value so that we can purchase it and help consumers to make the best choice for themselves and their families. Policy that encourages incremental improvements in one area almost always accelerates improvements in the others.
The impending crisis in health care in this country will not be averted, regardless of what happens to the Affordable Care Act, unless as a nation we move from fragmentation to integration, from volume- to value-based payment, and from paper records and stand-alone computers to interoperable and comprehensive electronic ones. If these delivery system issues are ignored in the rancorous debate about health care coverage, then no matter the outcome, the system will fail. We have a tremendous opportunity today to transform health care in this nation, and together we must embrace a new path forward.