For months, the US public has watched Congress debate the future of the US health care system—or more accurately—the future of the Affordable Care Act. But despite all we heard about deductibles and bronze versus silver plans, the debate in Washington was focused on the wrong thing. We can’t have affordable insurance until we have affordable health care, and we won’t have affordable health care until we address the drivers of rising health care costs.

The reasons that health care, and by extension, health insurance, costs so much are primarily: prices, waste, and the perverse incentives of our payment system. If policy makers, health care professionals, and other stakeholders are serious about making care more affordable—and accessible—we’re going to have to address the fundamentals of care and payment.

These issues were the focus of the National Affordability Summit sponsored by the Network for Regional Healthcare Improvement (NRHI) on September 27. Those gathered for the summit agreed that we must take on the challenge of health care affordability because the status quo is simply no longer an option. Between 2006 and 2016, the average premium contribution paid by US families with employer-sponsored health insurance increased by 77 percent, from $2,973 in 2006 to $5,277 in 2016. During the same period, median household income rose by just below 19 percent, from $48,451 to $57,617. According to a 2012 study published in the Annals of Family Medicine, if these trends continue and we don’t change the health care system, the average cost of a family health insurance premium will consume 50 percent of household income by 2021 and exceed the average household income by 2033. It’s no wonder that investments in infrastructure, education, and other societal priorities—many of which directly impact health—have declined as more and more money has been shifted to health care.

The good news is that with 30 percent of services deemed “low value” or “waste,” there is ample opportunity to bring down the cost of health care without reducing or compromising patient care. In fact, patients and providers are likely to embrace the needed changes. Reducing administrative waste driven by current insurance business models is a good place to start. No patient or provider will miss a proprietary measure set by a health plan that doesn’t actually improve quality—and reducing administrative burdens could have the added benefit of increasing physician satisfaction. No patient will lament a hospital or health system lowering its prices—particularly when they are required to pay a growing share of those prices and higher prices do not mean better care. Evidence from around the country shows that you can achieve better outcomes for patients with fewer hospitalizations, tests, and treatments when care is effectively managed and fairly paid for.

Leveraging Data To Innovate At The Community Level

The challenge facing those seeking to improve the system is that, so far, most efforts to control health care costs have been top-down affairs. But because of the diversity in markets across the states, and widely varying community needs, it is unlikely that a single national approach can be effective. It is equally unlikely that we will see a top-down national approach coming from this Congress or administration. The only sustainable and feasible way to reduce and slow increasing health care costs is to restructure health care delivery and payment systems from the bottom up—at the community level—with all stakeholders making needed changes, then diffusing the lessons they’ve learned.

This is where care is delivered, and where the most reliable data on what is driving costs can be found. To make it work, we need to bring together all the stakeholders including consumers, physicians, hospitals, health plans, businesses, and government. Payment and delivery system reforms are necessarily multistakeholder undertakings. Providers can redesign care delivery—but won’t be successful unless those paying for care change the payment structure to support them. And to truly improve health, new partnerships beyond the health care system will be necessary to address social determinants of health. Simply put, the most effective strategy for reducing costs and improving the health of populations is to develop and support multistakeholder community strategies based on accurate and actionable data and scale them nationally.

These collaborative efforts are already playing out—and succeeding—in communities around the country. For example, the Oregon Health Care Quality Corporation (Q Corp), now HealthInsight Oregon, joined with a number of partners to measure and report the total cost of care and resource use across Oregon for private payers, through a project sponsored by the NRHI and funded by the Robert Wood Johnson Foundation. Q Corp brought together subject matter experts in cost and health care delivery from health plans, providers, researchers, and consumers, to determine the best ways to share meaningful and understandable cost and utilization information with primary care providers. These providers can play a significant role in controlling costs for their patients through their referral patterns and contracts with health plans. Q Corp issued its first total cost of care and resource use reports in mid-2015 and received positive feedback from primary care practices, some of which began using the information to factor costs of care into their referrals and treatment plans. Since then, Oregon has continued to build on its efforts to increase transparency and affordability. They have released additional reports and expanded the audience to include the health plans that voluntarily provided the cost data; they are also making plans to release information on cost of care to the public.

Oregon was also one of five states included in a project to standardize the measurement and reporting of the total costs of care for commercial payers. In January 2017, the NRHI released a report that compares spending by commercial health insurance plans in five different regions (Utah; Maryland; St. Louis, Missouri; Minnesota; and Oregon)—think of it as the Dartmouth Atlas for commercial spending. This work can provide the necessary and granular insight to address the real drivers of cost while preserving and improving patient care. Health care costs are driven by a combination of price and use, and this report shows what percentage of cost increases are driven by each. There is no way to effectively achieve affordability without this information, but, prior to now, it has been simply unavailable.

There are similar success stories from all regions of the country that show what is possible when communities come together with the right data, the right leadership, and the right partnerships. These innovators are leveraging shared data, shared community aims, and multistakeholder engagement to make major impacts on seemingly intractable problems. For example:

Tulsa, Oklahoma

In 2012, MyHealth Access Network was selected as the convening organization for the Comprehensive Primary Care (CPC) initiative, a Centers for Medicare and Medicaid Services multipayer demonstration project. Working with Blue Cross and Blue Shield of Oklahoma, Community Care of Oklahoma, the Oklahoma HealthCare Authority (Oklahoma Medicaid), and a network of 68 primary care practices caring for 200,000 patients, the goal of CPC was to improve care, achieve better health for populations, and lower costs by strengthening primary care.

A team of experts in practice transformation leveraged data from the participating payers and MyHealth’s health information exchange (HIE) to teach practices how to provide higher-quality, cost-efficient care. Clinical data and claims were used to risk-stratify patients; identify gaps in care; and engage employers, insurers, and providers to work together to review the quality and cost of care. All practices shared their cost and performance data, which created a culture of collaboration and a focus on outcomes. As a result of improved care coordination, all-cause hospital admissions dropped significantly, with the cost of care for Medicare patients dropping 7 percent in year one and 5 percent in year two. This saved Medicare $10.8 million over two years. And, in addition to the cost savings, payers reported significantly improved use of preventive care services with each participating payer reporting improvement in several quality indicators.

Baton Rouge, Louisiana

In Baton Rouge, the Louisiana Health Care Quality Forum leverages its HIE to reduce non-emergent emergency department (ED) visits and inpatient admissions among the state’s Medicaid population. The Louisiana Emergency Department Information Exchange (LaEDIE) is a HIE application that receives and compiles utilization data from hospital EDs and notifies the appropriate Medicaid managed care health plan each time a member visits an ED. In turn, the health plan case management teams use the data to conduct timelier outreach, education, and follow-up with their members. In a LaEDIE pilot project that ran from August to December 2015, one of the major health plans reported that among its top-performing pediatrics practices, several had realized as much as a 20 percent reduction in ED visits per 1,000 members and more than a 10 percent reduction in inpatient admissions per 1,000 members.

In other communities, newer efforts show great promise. They are developing, testing, and spreading ways to reduce high-cost hospitalizations by addressing social determinants and providing needed services in the community.

Humboldt County, California

In Humboldt County, the North Coast Health Improvement and Information Network (NCHIIN) and the County Department of Health and Human Services (DHHS)–Social Services joined together to find a better way to care for people with complex health, behavioral, and social needs—or “super-utilizers.” They needed a way for the various systems of care that work with this population to access information necessary to provide appropriate support and reduce expensive and unnecessary repeat encounters.

The NCHIIN and the DHHS worked for 18 months to create and implement a system that alerts case managers if one of their super-utilizer clients has an interaction with a local health care facility and enables them to communicate and coordinate with the various providers involved in their clients’ care. One of the biggest challenges was the need to create an effective consent process for clients; but through a process that directly engaged the clients and paid heed to their concerns, they developed consent documents, FAQs, and scripts for staff that have proven successful in gaining the acceptance and participation of 180 super-utilizer clients.

These are just a few of many success stories in states from Maine to Hawaii that show what can be done when communities are willing to collaborate across sectors, share data, and implement bottom-up solutions.

We can no longer wait for Washington. Those of us in the health care field must join the physicians, employers, and other leaders around the country already taking on this challenge. We must build on efforts like those of Oregon; Oklahoma; Louisiana; and Humboldt County, California, that are bringing diverse stakeholders together to innovate and collaborate, and have collectively built the tools, data systems, and multistakeholder forums to make this possible. It won’t be easy, but care delivery and payment reform have the promise of producing better care at lower cost. Let’s start a new conversation about how to really change our nation’s health care status quo—we can’t afford not to.