Public understanding about how our health system operates is woefully low: surveys show only one in five adults has functional knowledge about how to choose a physician, hospital or insurance plan, or compare treatment options. The lexicon we use in our industry lends to this confusion: powerful words and phrases that convey something different depending on the user’s intent.
As we debate the replacement for the Affordable Care Act, it might be worthwhile to ask lawmakers to clarify what they mean when they use them and examine our own uses in tandem:
Quality: In U.S. healthcare, quality is not defined by a consistent set of metrics that address diagnostic accuracy and clinical outcomes. Physicians associate it with access to a clinician; insurers associate it with necessary care; employers with provider network scale and premium costs and the public thinks it’s about scheduling and parking, not results. There are a dozen websites where information about the quality of care in hospitals and medical practices is available, but each has its own methodology and results vary widely. As a result, every hospital and every physician affirms they deliver “high quality care” and every insurer tells its enrollees, groups and regulators its plans are “high quality”. Little wonder quality is confusing.
Affordability: Healthcare affordability is an abstract concept: in the U.S., it’s theoretically a relationship between total out of pocket payments as a percent of household income for premiums, co-pays, deductibles, and over the counter therapies. But there’s no consensus about what constitutes an acceptable level of affordability. In the Affordable Care Act, a threshold above 9.5% was deemed appropriate for employer-sponsored insurance premium affordability, but insurance premiums vary widely based on what’s covered and much isn’t. And is affordability when applied to healthcare spending a different calculus when compared to housing and food expenditures which seem more straightforward?
Access: Does giving individuals the opportunity to purchase an insurance plan or see a specific physician that’s out of their reach financially constitute accessibility? In the Veteran’s Health Administration, a standard for access to primary care is 30 days or less and vets have no co-pays: it’s a straightforward standard for access. There are no standards for access to physicians, hospitals, therapies or other time-sensitive products and services in our system. Should there be?
Value: The most over-used word in our lexicon is value. Each stakeholder calculates the costs and outcomes of their output differently and conveniently each result is “high value”. In the Affordable Care Act, value was codified for hospitals around the Hospital Value Based Purchasing Program that specified metrics for determining hospital value. Each sector in healthcare opines about its value proposition offering metrics that are prone to self-preservation.
Costs: Policy-makers calculate health spending in the U.S. based on what’s spent for providers, drugs, facilities, technologies, insurance and administration concluding the U.S. system is the world’s most costly. But our pluralistic payer system combined with the 10% whose care is paid for by others means providers, especially hospitals, end up providing social services that are calculated differently in other systems of the world. As a result, total spending on healthcare, as a percent of GDP, is actually higher in France, Sweden, Switzerland, Germany and the Netherlands than in the U.S. And in all of these, the total is well above 25% of their GDP.
And there are many other terms and phrases that play key roles in healthcare shorthand: accountable care, comparative effectiveness and evidence-based care, healthcare consumerism, physician-patient relationships and patient centered care, precision medicine, alternative health and many more. Each of these mean something different to the users, and rarely is there consistency in implied intent.
Regrettably, after seven years of debate about the transformation of the health system, the public’s still confused by our lingo. The era of social media and 24/7 news cycles lends to soundbites that obfuscates understanding. Just as “fake news” and “alternative facts” are now part of our political discourse, so is our dependence on terms and phrases that mislead or confuse.
Maybe as we engage in Health Reform 2.0, we should develop a glossary of key words and phrases so we aren’t lending to the public’s confusion about what we mean. It’s worth the effort.
P.S. Some common themes are emerging from the GOP’s efforts to repeal the affordable care act. First, the process will involve executive orders, legislation and new regulations all on the table by the end of this year. Suspension of the individual and employer mandates will be among the first wave of these orders. Second, implementation will be phased over a 2-3 year period, with much of the responsibility shifting to states for Medicaid, insurance coverage and more. Three, it’s unlikely Medicare reforms, in the form of a premium support replacement, will get thru Congress, but limits on supplemental coverage and expansion of Medicare Part C plans are likely to advance. Fourth, insurance coverage permitting purchases across state lines in tandem with expansion of high risk pools will be on the table. Lawmakers will make concessions to insurers including a requirement for continuous coverage for those with pre-existing conditions, and income-based tax credits so lower income individuals can purchase coverage will continue. Stay tuned. The question is this: how will the campaign promises by President Trump, the cost cutting appetite in the Freedom Caucus and the looming Campaign 2018 battle factor into the final product?
Paul H. Keckley is Managing Editor of The Keckley Report, a healthcare researcher and widely known industry expert.