Is there hope for healthcare? What would you do?

These are the recurring questions from my students and colleagues. My response, I think there is hope. After all, the past 40 years have shown that the stakeholders in the healthcare system can self-organize to maximize their own sectors based on incentives, we are where we are now because the system maximized the incentives of fee-for-service (FFS), provider price controls, relative value units (RVUs), and the Bayh-Dole act. These incentives exist in an industry further characterized by heavy reliance on employer-based healthcare coverage and a total hodge-podge of health insurance for individuals who are not employed, disabled, or retired. While still leaving tens of millions uninsured. And the sum of it all just happens to benefit providers, private insurers, device manufacturers and biotech, pharma, politicians, and lawyers.  

Given that incentives can change the healthcare system, “reform the system”, here are three tactics that would force stakeholders to change, ultimately leading the system to self-reorganize:  1) Coverage for all; 2) Alternative payment models; 3) Investment in public health.  These are not listed in a priority order; they have to be tackled simultaneously.  

Coverage for all:  

• Individuals own their insurance.  
• Insurance is not linked to employment (although employers could help offset the cost of employee insurance premiums, if the employers so desire).  
• Everyone is in the same insurance scheme.  
• It could be a single government payer; or a single exchange of commercial insurers (like the Federal Employee Health Benefit Program or the DC Shop, which is the ACA exchange in DC which Federal elected officials set up for themselves and their staff in order to claim they are in the ACA); or Medicare Advantage plans for all.  
• Since this is the US and since choice is so important to so many, a single government payer is not likely.  Certainly, the Obama administration found that support for a Medicare-for-all plan was lacking even among Democrats.  
• Individuals should have choice and be able to opt for additional coverage and different levels of co-pay and deductibles, if so desired
• The government has a big role to play in maintaining affordability in whatever model of insurance scheme is chosen.

Alternative payment models: 

All of which must have a common set of goals that lead to high value care, better results, lower costs, elimination of avoidable admissions and ED visits, better wellness, more prevention programs, and improved health. These goals will require tactics at all four levels of prevention both for individuals and for populations. These goals will also require incorporating tactics to improve the social determinants of health (SDOH ) – which will require participation by providers, public health experts, and legislatures. No one single group has total control over the entire spectrum of the SDOH, which includes education, employment, housing, sanitation, safety, etc. 

Specific goals for provider payment models:

• Encourage a relentless focus on quaternary prevention for those with acute illness and hospital care. Get it right the first time, every time, on time, no waste, no complications, no side effects. 
• Encourage tertiary prevention for all those with chronic medical conditions and secondary prevention for those at risk for developing chronic conditions.
• Encourage providers to improve the health of at-risk populations, which requires a relentless focus on the sickest people in the population, and the development of personalized treatment and behavioral management techniques for each person in a given at-risk population.  
• Encourage providers to engage with and improve SDOH that they can influence, if not control, in the following categories: personal behaviors, genetics, environment, nutrition, drugs, suicide.

There are several examples of new models of payment that have resulted in new models of care: bundled payments for populations (disease specific; geographic, or focused on the sickest most expensive patients in a given population); full capitation; per member per month (PMPM) capitation, etc.    

Investment in public health and primary prevention:

This will be the hardest to accomplish.  I do not see the government putting more money into individual health and population health.  After all, we already have a National Institutes of HEALTH (NIH) and look how they prioritize the use of their $30-40B/year funding. Given its primary focus on basic biomedical research, the NIH does not seem to be aptly named.  

Public health will improve if and only if the country gets serious about the health of our citizens and views the health of the population as a national security issue. This will require a shared vision coupled with a long-term commitment to a mission of and funding for health (just as we do for basic research). Freeing up money for health-related initiatives is where the healthcare delivery system can play a major role. If new payment models accomplish the goals listed above, the USA will save 15-30% of the current annual spending for healthcare delivery. Given an annual spending of $3.5T/year that would free up between $525B to $1.05T/year that could be used to outperform the NIH with a focus on public health and improve all aspects of the SDOH including mentioned above: housing, education, safety, environment, jobs.    

Denis A. Cortese

Dec. 28, 2020