As CEO of Harvard Pilgrim, I find I do a fair amount of public speaking. Over the past ten days or so, I’ve been on several panels with a variety of public policy, health policy and industry types. We also represented a pretty broad collection of political philosophies – some Democrats, some Republicans, some liberals, some moderates and some conservatives.
What really struck me, though, was the amount of cross-over support several policy ideas had in the “what do we need to do about health care” arena. To listen to the media, one would conclude there is no common ground between the parties on this issue – and, frankly, a lot of the stuff the people I was with were talking about hasn’t really showed up on the national debate scene at all.
So – at the risk of over-simplifying what my fellow panelists and I talked about during these discussions – I’d offer up these four national policy ideas – all of which seemed to have pretty broad ideological support.
1) Encourage Medicare to pay more for primary care, and less for specialty care. The whole evolution of the Medicare physician fee schedule for the past thirty years has been to pay more for technology and less for time. As a result, the whole health care system pays more for technology and less for time, since all the payors shadow Medicare payment policy. This trend has resulted in more specialists, fewer primary care providers, and an increasingly fragmented care delivery system. One speaker put it this way – “As long as a dermatologist can make three times as much as a primary care provider and work half as many hours, very few medical school students are going to go into primary care.” This isn’t about picking on dermatology – but the point is a good one.
2) Start doing some Medicare demonstrations in which Medicare pays for clinical outcomes and not simply for volume. As it stands now, the whole system is primarily built on a fee for service platform – so the key to revenue generation is to do more stuff. If we ever want to encourage quality first, we have to figure out a way to pay for it – one illness at a time. Medicare is the biggest payor. More than any other, it can re-wire payment away from just paying for volume and into paying for quality.
3) Fix the relationship between Medicare and Medicaid for low-income seniors who qualify for both programs. As it stands now, neither program coordinates any of its activities or payment policies with the other, and the result is a tangled mess of incredibly expensive, overly bureaucratic ping pong between the two agencies – with the often frail, medically needy, low income senior sitting in the middle. The few times states have done demonstrations to organize and coordinate how Medicare and Medicaid serve this population, the result has been higher quality care, better health status – and HUGE SAVINGS for both programs.
4) Make living healthier lives a priority. Professor David Nash at Jefferson College has estimated that only 3 percent of Americans do the four simple things that matter most in living a healthy life:
– Don’t smoke (we’ve actually made a lot of progress on this one, and it shows)
– Eat a decent amount of fruits and vegetables
– Get some exercise (20 minutes, three times a week)
– Try to live somewhere near the “normal” weight for someone your height.
According to Nash, if merely 10 percent of Americans could pull this off, the impact on health care costs would be gigantic – in the right direction.
We talked about many other issues during these discussions, too – some of which are on the national debate agenda, but most are not. These included:
1) Cover everybody (surprise!). But on this one, the discussion focused more on having the federal government help pay for coverage expansions through Medicaid reimbursement expansions (like Massachusetts), rather than having the federal government do it themselves.
2) Do something about practice pattern variation. This one is a hot topic among the policy folks, but never gets into the public debate. Why? I suspect no one in politics wants to take on the notion that everything that’s done in health care isn’t “necessary.” Well I’ve got news for the politicians. If you want to do anything about the cost of care, you have to wrestle with this topic.
3) Squeeze the health insurance companies. Okay – I’ll be the first to admit that this one is a crowd pleaser, but at the end of the day, squeezing the insurance companies saves pennies on the dollar. Most independent studies indicate that plan administration represents less than 10% of total health care spending, so reducing it by 2-3% doesn’t really solve the problem. Every penny helps, I suppose, but no one’s going to solve the health care cost crisis by simply taking it out on the plans. There’s not enough money there to support more than a few months’ worth of medical expense trend.
4) Spend more federal research money on understanding how we apply the science we already know in the care delivery arena, and less on advancing basic science. If we really want to improve care delivery and enhance the cost/quality of the system overall, we have to start studying how and why we do what we do now, and the impact that has on outcomes. Simply advancing basic science without focusing on how we apply what we learn only answers half the question.
There were other topics as well – including transparency (but that came mostly from me). But what I found was a surprisingly large amount of common ground on what could be done. More importantly, a lot of the discussion was about improving quality and reducing the growth in medical expense trend – both of which can and should be priorities for the next President and the next Congress – with or without a federal budget deficit.
I do wish I saw more of this kind of talk in the public debates – and not just in the small-time ones I’m participating in.