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Asking Americans to improve their health should not be too much to ask.
Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform.The opinions expressed here are that of the authors and not UBM / Medical Economics.
There is a national debate on restructuring healthcare in the United States. In 2016, healthcare spending was $3.3 trillion, representing 17.9 percent of the U.S. economy, according to CMS. The $10,348 U.S. per-capita healthcare cost is double that of other western societies that have far less regulation. A comprehensive overhaul of U.S. healthcare including Medicare, Medicaid, and private health insurance is required. This should include a critical look at the effects of regulation on healthcare cost. A shift in policy from regulating healthcare organizations and practitioners to healthcare consumers may incentivize an improvement in public health with a reduction in cost.
Healthcare regulations including Medicare, HIPAA, HITECH, ACA, and MACRA number over 212,000 pages. This is equivalent to 144 copies of my 1977 Gray’s Anatomy text and three times the volume of the tax code. This does not include state regulations. By comparison, the 1984 Canada Health Act, covering all Canadians, numbers 14 pages divided between English and French translations with medical care delivered by each province. In Alberta, for instance, there are 30 healthcare laws and 100 schedules totaling 2,227 pages presented on the provincial website. The 1946 British National Health Services Act, which established a national healthcare system, numbered only 94 pages. It was revised in 2006 to 273 pages. Recently the National Health Service imposed a measure of patient responsibility. Smokers must quit for six months and obese patients must lose weight for six months prior to receiving elective surgery.
U.S. healthcare regulation unlike healthcare services has no requirement to be evidence-based or cost effective. It therefore seems unlikely that more regulation of clinicians will make U.S. healthcare less expensive and of higher quality.
Some estimates suggest that up to a third of health spending is consumed in regulatory compliance. U.S. healthcare regulation increasingly mandates how physicians practice with an emphasis on expensive and inefficient information technology (IT) systems. A Medical Group Management Association survey of 3100 practices in 2016 found that HITECH Act compliance alone costs each physician $32,000 per year in expenses.
Members of the U.S. Senate have concluded that the government’s $35 billion IT investment to computerize private healthcare delivery has not achieved it goals. The American Hospital Association estimates hospitals spend $35 billion annually on overall regulatory compliance. Increasingly, IT costs go towards providing data to the government rather than delivering patient care. Between 2006 and 2013, CMS increased the number of quality measures from 119 to 822 and quality programs from 5 to 25.
Data-driven, “performance-based” compensation tries to link payment to patient outcomes. Outcome, which may be influenced by comorbidity, patient adherence, and medication coverage, is used as a surrogate for quality of care. Some new payment models such as Tennessee’s Episode of Care system provide “gain sharing” payments to physicians who provide inexpensive care and require physicians to refund payments for patients with excessive costs. This penalizes care of the most complex and least cooperative patients. It also creates a conflict of interest for physicians who now have personal financial considerations potentially influencing their decision making. Thus the government is seeking to reverse the philosophy of physician financial independence created in the pharma guidelines. It is concerning that financial penalties imposed by CMS for congestive heart failure readmissions has been associated with an increase in the short- and long-term mortality of Medicare patients. Perhaps financial incentives and penalties should be shifted from healthcare providers based on the cost of the care they deliver, to the patients based on their control of cardiovascular risk factors.
‘All pre-existing conditions are not the same’
Healthcare rules do not regulate patients who are the consumers of medical resources. The underwriting of life, disability, automotive, casualty, and malpractice insurance is based on calculated risk. This incentivizes insured individuals to minimize their risk and thereby decrease their premium and deductible expenses. In so doing, it reduces insurance costs for losses. There is public opposition to considering pre-existing illnesses when underwriting commercial health insurance or paying into Medicare. The ACA mandates that pre existing illnesses must be covered and cannot affect premium cost.
However, all pre-existing conditions are not the same. For instance, some conditions occur through no fault of the patient, such as congenital heart disease, breast cancer, and degenerative neurologic diseases. Alternatively some other conditions are controllable cardiovascular risk factors (CRFs), such as hypertension, diabetes, high cholesterol, smoking, and obesity. These controllable conditions substantially drive health costs. A study of Medicare patients with and without known cardiovascular disease (CVD), found those with a poor CRF profile had annual healthcare expenditures that were double the expenditures of those patients with an optimal CRF profile. Healthcare reform favoring control of CRFs could help prevent CVD, improve overall health, and possibly shift more patients with or without CVD into the lower healthcare cost groups.
Patient adherence with medical care is an important factor in CRF control. One report suggested that patient medication non-adherence alone accounts for an estimated $100 to $300 billion of avoidable annual healthcare costs. Adherence with weight loss, exercise, and smoking cessation would further reduce the risk of cardiovascular disease, stroke, kidney disease, and lung disease. These diseases are major causes of death and disability, and major drivers of healthcare costs. Non-adherence prior to age 65 contributes to chronic diseases paid for by Medicare later in life. Additionally, uncontrolled CRFs contribute to premature disability, which is also paid for by Medicare. Individuals with uncontrolled CRFs contribute into Medicare the same as those with controlled CRFs but utilize more resources. Those individuals who pay for and take medications to control their own CRFs subsidize the medical care of non-adherent individuals.
Shifting risk to the patient, not the physician
Healthcare reform should shift the burden of regulation from healthcare organizations and physicians to the public with respect to CRF control. An inexpensive, annual government-provided evaluation of smoking status, BMI, blood pressure, and serum measurements of LDL cholesterol and hemoglobin A1C, could be used to determine an individual’s risk. Medicare contributions and insurance premiums could be reduced for individuals who control their CRFs and increased for those who do not demonstrate CRF control.
Thus individuals who elect not to be tested would be placed in the high-risk and high-premium group. This would incentivize individuals who do not receive medical care to obtain a free assessment of their risk factors, and incentivize everyone to improve their risk profile and their health. It would also give patients an independent assessment of the adequacy of the risk factor medical care provided by their practitioners. A phase-in period would be needed to allow patients to optimize their CRF control before paying higher insurance premiums and Medicare contributions. The informed patient, not the government, would become the judge of the quality of their medical care.
Physician reporting of quality data to the government could be reduced with a reduction in overhead cost and physician dissatisfaction. To incentivize those already receiving Medicare benefits to maintain CRF control, the extent of coverage might also be linked to their risk score. Rather than Medicare paying a fixed 80 percent of patient bills, this could be adjusted based on the risk score. Non-adherent individuals with uncontrolled risk factors would pay more or purchase gap insurance covering more than 20 percent at increased personal cost. Conversely, adherent low risk profile individuals would receive greater than 80 percent coverage.
In shifting the financial responsibility of CRF control to patients, cost should not be an impediment to adherence. It will be incumbent on the healthcare insurance and pharmaceutical industries to provide them with the medications they need at an affordable cost. Spending on CRF control is cost effective. Increased spending on hypertension and diabetes medications from 1996 through 2013 was accompanied by a decreased prevalence of cardiovascular disease and a 20.7 percent reduction in spending . Additional investment in risk factor control may hopefully improve the health of our society and thereby reduce the cost of care. This model might also be applicable to other risk factors involving other medical disciplines.
Healthcare policy is crafted at the intersection of science and politics. The science is clear that improving risk factor control can improve health and reduce cost. How then can the politicians and the public be motivated to adopt this type of reform? President John F. Kennedy famously asked Americans to “…ask what you can do for your country.” Perhaps one answer is to eat better, exercise more, and take your medicine. Asking Americans to improve their health should not be too much to ask. Democrats and Republicans in Congress should exercise a profile in courage and introduce patient accountability into healthcare reform.
Thomas Little, MD, FACC, FSCAI, is a cardiologist with Cookeville Regional Medical Center in Cookeville, Tenn.