Healthcare Musings For February 26, 2021

 

February 26, 2021

Dear Interested Readers,

 

Can We Balance Regulatory and Competitive Approaches to Promoting a High Performing Health System?

 

This is the sixth and final installment of my review of the report of the Commonwealth Fund’s task force on payment and delivery system reform. On November 17, 2020, the Commonwealth Fund published the report of over a year of deliberations by a panel of healthcare policy and practice experts that they had convened. The report is entitled Health Care Payment and Delivery System Reform: Six Policy Imperatives. 

 

In a plodding fashion over the last three weeks, I have devoted one post for each “policy imperative.” I have reviewed a lot of articles and books in these notes over the last thirteen years, but I have never spent so much time with one item. I saw the Commonwealth Fund’s task force report as a great starting place for developing an agenda for the Biden administration’s attempt to resume the journey toward better healthcare for every American and better health for the nation after a four-year hiatus during which the momentum toward the objectives of the Triple Aim was lost. If you have not read the last five posts, nothing has been lost that you can’t recover by clicking on the link above and downloading the report which you can then study on your own. 

 

I have been mostly in agreement with the recommendations of the task force. I respect all of the task force members. I know many of them by reputation and have had personal interactions with several of the participants. I have enormous respect for the work of the Commonwealth Fund. I am an avid consumer of all that they publish and I believe that under the leadership of David Blumenthal they are diligently working toward their vision of:

 

Affordable, quality healthcare. For everyone.

 

During the review of the first four imperatives, I found myself in almost total agreement. If you read the post from Tuesday you know that in the fifth imperative I found reasons for some disagreement.  Essentially, I felt that the task force’s recommendation was much too focused on the administrative barriers facing physicians and institutions with little or no acknowledgment of the enormous barriers and inconveniences that patients encounter. 

 

Ironically, on Wednesday I experienced my own encounter with the dysfunctional administration of healthcare. I received a “MyChart” notice that I owed $402.00 for a telehealth annual review that I had a few weeks ago. It was interesting to me since I have never had a similar charge for an “in-person” annual health review. First, I was shocked by the price. That sticker shock aside, I noted that the bill said that Blue Cross had paid nothing. My wife and I are covered by her Federal Blue Cross Retirees Health Insurance. It’s definitely not free and we have coinsurance payments and deductibles, but we chose it for reasons of initial expense and convenience over Medicare Part B. When I went to my account on the Blue Cross website, I saw payments for an orthopedic visit and physical therapy in January, but no evidence that they even knew I had had a televisit in early January. It was all very strange since I have never had a charge for a “health maintenance” visit. One of the important provisions of the ACA is to ensure access to preventative care. I am a fortunate individual in that I can absorb a $400 surprise healthcare bill. In the end, I expect that I will have to pay. But, before the pandemic, it was well documented that 40% of Americans can not absorb an unexpected bill of $400. Now, after the jobs lost to the pandemic and in a time when more and more “middle class” people are forced to go to food banks, I am sure the number is higher.

 

I sent my PCP a MyChart note asking if she could explain what had happened. I thought that perhaps there was a clerical error. She wrote back quickly that she was exploring the issue. She was surprised that I had been billed. In a few hours, I got a call from the accounting and billing office with an explanation. Apparently Federal Blue Cross decided that it was not going to cover these visits after January 1. They failed to notify either patients or providers. I was not the first person who had been surprised. The finance department at Atrius Health advised that I call Blue Cross and register my complaint and ask for an exception since neither I nor my provider had been notified of their unilateral change in payment policy for televisits.  What I learned raised another question that puzzles me. Why in a time of growing acceptance of telehealth would Blue Cross decide not to cover a visit like the one I had?

 

After about a half-hour trying to get through the automated menu of Blue Cross, I had to give up because I had a Zoom board meeting. I will try again in a few days when I can spend a few hours on the task. I don’t expect satisfaction. Why should I? I have no leverage. Blue Cross can abuse me and a host of other patients without the expectation of any change in their overall profitability. Suffice it to say, there are enormous administrative barriers for healthcare providers and for patients. In a bad system of care, everyone is vulnerable. 

 

I present this personal information to underline the fact that the task force did not mention the administrative burdens and frustrations of patients. The system doesn’t work well for doctors and other healthcare professionals and it is even worse for patients and families. I was a little surprised by the report’s lack of “patient-centeredness.” I find that I also have some differences in point of view with the task force’s sixth set of policy recommendations, “Encourage a Balance of Regulatory and Competitive Approaches to Promoting a High-Performing Health System.”

 

As with the other sections, the introduction is fabulous:

 

Creating a high-performing health system requires that we address flaws in the functioning of health care markets that threaten the efficiency and quality of care. Other recommendations in this report…will be more effective if they are accompanied by efforts to remedy notable market failures. 

The U.S. is unusual among high-income countries in its heavy reliance on market forces and competition to allocate health care resources. The country’s widespread belief in the efficacy of competition as a way of improving the health care system suggests that any reform strategy must fully explore the possibilities of increased competition for improving the delivery of services. At the same time, leaving the distribution of health care exclusively to market forces has potential costs and drawbacks, including the favoring of individuals and communities with more resources — for both the purchase and the provision of services — which in turn aggravates inequities, particularly those related to race and ethnicity. These drawbacks have led other high-income countries to rely much more heavily on government controls and regulatory interventions. 

Health care in the U.S. is characterized by high health care prices, high spending, shortages of vital and low-cost services like primary care, and underinvestment in less-profitable geographic areas, such as rural regions. Research points to problems that make it extremely difficult for markets to function as they should in theory, including distortions in payment systems, massive consolidation among providers, outdated antitrust law and enforcement policies, and lack of publicly available information about prices. 

 

My objection to the report of the task force is that after they note the failure of trying to improve healthcare through competition and market forces they suggest that we try it again. Their recommendations might work if there was really a driving reason for a change to occur. There isn’t. The fact that we spend close to 20% of GDP on care that excludes millions and abuses hundreds of thousands of people a year and can’t see reason in those facts to drive change makes me very skeptical that the policy tweaks that follow will lead to meaningful change. But read on:

 

Below we outline recommendations that consider regulatory and competitive approaches to producing lower costs and meaningful benefits for patients, including better quality and greater equity. These recommendations include measures the federal government can take to enable diverse purchasers and providers to become more effective participants in a wide range of health care transactions. We also lay out recommendations to promote greater competition and transparency in the prescription drug market and suggest areas that should be the subject of intensive investigation — since whether effective competition can be established in health care, and whether it will achieve the intended objectives, remains a matter of debate. 

 

My three-week review of the recommendations of the task force should not be interpreted as an objection to the changes they advocate. I just don’t think we can get to where we need to go through any tweaks of the market or legislation that seeks to create incentives for change through greater transparency or governmental manipulation of the healthcare market. Healthcare may function as a market in some of our larger cities but I would argue that consolidations have diminished real competition and that consumers have demonstrated that the complexities and emotional issues associated with care will always make the purchase of healthcare different from buying a car or choosing a cell phone provider. 

 

You should read the suggestions of the task force. In a world where providers and payers embraced the necessity of change, they might work. In a world of militant consumers who recognized that they needed to be concerned about the health of their neighbors to protect their own health, these suggestions might make a difference. Despite high costs, poor service, and outcomes that are little better than achieved in some third world countries, a diminishing majority of Americans don’t want to risk change. Since public policy changes in this country can be blocked by well-organized and self-interested minorities, I fear that the recommendations of the task force will bear little fruit. 

 

I think the best recommendation is to “Regulate Markets in Areas Where Competition Is Deemed Absent or Ineffective.” When a woman needs to drive over fifty miles to get obstetrical care it is ridiculous to imagine that market forces will improve the quality or cost of the care she receives. I also agree that we should “Enhance Competition Through Strengthened Antitrust Enforcement Related to Provider Systems and Payers.” If we believe that markets might work where there is a choice of providers, it is hard to imagine that the ease of medical consolidations over the last decade has created much measurable benefit. Every consolidation with which I have had experience was presented for approval with the promise of benefit for consumers. Most of them did not yield consumer benefits but did provide bargaining strength for higher reimbursement. 

 

There is much that regulations might accomplish in the lowering of the cost of care through lowering drug costs. The task force recommends that the 340B Drug Pricing Program be revisited and reformed. The 340B drug program was conceptualized in the early ’90s as a way to use the leverage of government to lower the cost of care for poor and disadvantaged patients through rebates as a way of lowering costs for hospitals and practices that served the poor. These days the 340B program has become an excellent source of revenue for hospitals and practices that are more oriented to making a margin than serving the underserved. Healthcare is so complex that good intentions are frequently twisted to serve objectives that are 180 degrees from the original intent. The best example I know of this frustrating reality is RVU based compensation. The original intent of RVUs was to narrow the spread between compensation for specialists and primary care. As we all know the outcome was the exact opposite of the intent. 

 

We must keep trying to make healthcare better, but I am not convinced that we will accomplish our objective by making healthcare a better performing market that we essentially allow to regulate itself. If that was possible it would have happened many decades ago. The task force report is an excellent resource that gives an in-depth description of the challenges ahead and the outcomes we need, but I am not so sure that we will get to the desire to have…

 

Affordable, quality healthcare. For everyone.

 

…without recognizing the need for even greater change. That recognition must come from within healthcare. Healthcare will work better for everyone when healthcare makes healthcare for everyone its most important objective. 

 

The Longer Days Are Nice!

 

I miss most sunrises. The sun has usually been up for a few hours before I begin to loosen up all the body parts that froze overnight. By the time I get moving a lot of people are on their third Zoom meeting. I am a big connoisseur of sunsets and pay a lot of attention to when the sun is scheduled to go down. My only real objection to winter is that by mid-December the sunset where I live is around four o’clock. If there is anything that is a signal that winter is on its way out, it is when sunset begins to get noticeably later. This last week the sun was going down after 5:30! Daylight savings time is just a little more than two weeks away!

 

In the dead of midwinter the sun goes down and it is immediately pitch black dark. As the days get longer we begin to have a little twilight. By mid-June, the twilight will last almost an hour. I really enjoy that time between when the sun sets and “night” begins. 

 

I think the view of Mount Sunapee from the crest on Burpee Hill Road is my favorite vista on all my local walks. I have used this view of Mount Sunapee as the header for these notes before, but this week I was walking in the very late afternoon and came to my favorite view shortly after the official time for sunset, but while there was still a lot of light. My only complaint with the picture is that it obscures the over five hundred foot downhill flow of elevation from where I was standing to the lake. Lake Sunapee appears in the picture as the snow-covered surface which you can see at the foot of the mountain with its ski runs. The picture lacks the sense of depth that allows an appreciation of the drop in elevation. Distances are also distorted. The mountain is about ten miles away. The beauty that caught my eye that my iPhone camera also diminished is the twilight colors in the western sky. Despite those flaws, I thought the picture was a nice presentation of the evening sky in late winter and I wanted to share it with you.

 

When I took the picture there was a brisk wind that made it feel substantially colder than the 21 degrees that my weather app told me was the real temp. We are at that strange moment in the course of winter when it is still winter, but you know that winter’s days are numbered. Two days later it was 42! The long-range forecast for next week is for several days to be in the mid to high thirties. Mud season is just around the corner! I hope that you will be out and enjoying the longer days this weekend. 

 

Be well, send me your thoughts on the issues that challenge us or your celebrations of what you see that gives you hope!

Gene