The Republican agenda to repeal and replace the Affordable Care Act will fulfill campaign promises, but misses the point of healthcare policy: Optimizing Americans’ health in an economically sustainable way. Isn’t that really what we’ve been arguing about for the past eight years? Shouldn’t that be the focus?
Healthcare is a massive expense for the United States and the tragic truth is our outcomes are exceptionally poor compared to our expenditure. The progression of chronic diseases represents majority of the expenditures. According to the Centers for Disease Control and Prevention, chronic diseases account for 75% of healthcare spending. Four percent of GDP is spent on diabetes alone. If the Graham-Cassidy bill were to pass, it would result in many chronic diseases going unchecked and untreated. This would not decrease cost.
Complications of poorly managed chronic diseases, not the treatment of the conditions themselves, account for the bulk of healthcare expenditures. Our fee-for-service healthcare system inadvertently created disincentives for effectively keeping chronic conditions like diabetes and hypertension in check as hospitals, doctors, and insurers made more money on acute complications requiring hospitalization, surgery, or intensive intervention than they did on day-to-day interactions required to keep chronic diseases under control. In fact, there was no mechanism to reward clinicians for keeping their patients healthy. The Affordable Care Act (ACA) was a step in the right direction to address this fundamental flaw in our healthcare system. Accountable Care Organizations and Alternate Payment Models were created to reward those doctors and healthcare systems that meet certain quality benchmarks.
Certain aspects of ACA are very unpopular with opponents of the law, especially the individual mandate. The latest proposal scraps the mandate, ends ACA tax credits and subsidies, and lets states decide if they want to keep protections for people with preexisting conditions (chronic diseases – those conditions we mentioned that drive the majority of our healthcare cost). Instead, the bill allocates $1.42 trillion for block grants to states. The hypothesis is that the states will find a more efficient and effective way to spend this money.
What could we achieve if we focused this energy on the policies that really affect how care is delivered and paid for on the front lines?
If the goal is to improve health outcomes so that we move up in global life expectancy rankings (we are currently number 31) and don’t bankrupt our country (we’re spending nearly 20% of GDP on healthcare), then Congress must focus on policies that affect those two goals. The solution is not a new law that shifts the burden of figuring this out to the States and risks leaving more people uninsured; it’s smarter use of regulations to drive change throughout the system.
For instance, we need Health and Human Services to remove barriers to implementing novel healthcare delivery models like remote patient monitoring and telemedicine. There’s extensive data to show that these systems work when deployed strategically. We now have the ability to deploy them broadly and cost-effectively using technology that is already in patients hands like smartphones, wearables, and bluetooth-enabled devices. We can finally do this at scale. So why aren’t we doing it? Because most doctors do not get paid for interacting with their patients unless they see those patients face-to-face in their office, let’s change that.
Additionally, lack of physical activity, poor nutrition, tobacco use, and high alcohol use are major contributors to chronic diseases. These lifestyle habits require behavioral changes that are notoriously difficult. Educating patients about the importance of their role in managing their health is a time-consuming task for which there is inadequate time during a primary care visit. So why are we trying to cram it in to those 6 minutes? We need to start thinking about asynchronous workflows in medicine and leverage the kinds of technologies that have driven efficiency in other areas of business. What if physicians routinely prescribe YouTube videos to watch? What if physician practices implemented Slack as a means to communicate with patients? Imagine the impact that would have.
It’s all about scalability.
We have the knowledge, talent, and passion in healthcare to make our country healthier. We need to empower healthcare providers with tools that expand their reach and their impact. This requires aligning payment models and regulations to allow for new models of care delivery. The Centers for Medicare and Medicaid Services (CMS) limits technologies, and therefore provider usage patterns, to a certified list, narrowing provider and patient options. CMS plays an important role in ensuring the safety and efficacy of treatment modalities by regulating which options are reimbursed. It also needs to incentivize healthcare providers to focus on meaningful improvements in health outcomes and allow them to leverage innovations such as asynchronous remote monitoring and communications technologies.
Block grants to states would allow for more flexibility and creativity if such limitations were also addressed. However, passing the buck to the states without also addressing existing regulatory hurdles to innovation will result in fewer insured Americans and a continuation of our skyrocketing healthcare costs.
It is tempting to simply cut costs today rather than focus on changes to the Affordable Care Act that will pay dividends in the long-term via lower average cost per patient and fewer complications. But, if the administration and Congress can promote innovation through regulatory authority, realigning incentives, they can still work toward a more efficient use of healthcare dollars and we can achieve that simple goal of better health and economic sustainability.