3 health care ques­tions we should ask can­di­dates

The Morning Call - - TOWN SQUARE A PLACE TO BE HEARD - Robert McDon­ald is an ad­junct pro­fes­sor of health sys­tems en­gi­neer­ing at Beth­le­hem’s Le­high Univer­sity.

U.S. health care is a mess. One of the root causes is lack of price trans­parency. Lack of price trans­parency causes what the econ­o­mists call “in­elas­tic­ity.” In lay­man’s terms, this means the in­abil­ity to com­pare and choose ser­vices by the ac­tual cost and value of the ser­vice. What other ser­vice would Amer­i­cans buy without know­ing the price?

In an ef­fort to ad­dress this prob­lem, Pres­i­dent Don­ald Trump re­cently is­sued an ex­ec­u­tive or­der re­quir­ing the post­ing of prices for health care ser­vices. This fol- lows an ear­lier ex­ec­u­tive or­der re­quir­ing tele­vi­sion phar­ma­ceu­ti­cal ads to dis­close the price of the drug be­ing ad­ver­tised. This is a good start, but it is not enough to “bend the cost curve.”

Here are three health care ques­tions all can­di­dates should have a po­si­tion on:

1. What is your ap­proach to price trans­parency?

Why should the cost of health care be a se­cret? Why shouldn’t I know if dif­fer­ent providers give greater value (in health care, value is the com­bi­na­tion of clinical ef­fec­tive­ness and cost) for the same or even a lower price? You wouldn’t de­cide to buy a car without know­ing the costs. For some­thing as im­por­tant as health care, shouldn’t we all know what is be­ing charged? Why wouldn’t you want to know the ap­prox­i­mate cost in ad­vance and whether that ser­vice provider is pro­vid­ing the best value?

2. What is your plan for mak­ing providers and pay­ers more re­spon­sive to the cost of health care?

For years there have been dis­cus­sions about the moral hazard of in­sur­ance. Moral hazard is the in­cen­tiviza­tion of risky be­hav­ior or ac­tiv­ity by elim­i­nat­ing or re­duc­ing the eco­nomic con­se­quences. In the con­text of health care, this trans­lates to us­ing more tests and pro­ce­dures than may be nec­es­sary be­cause the gov­ern­ment or in­sur­ers pay the bill. As a wise man once wrote, “there is no free lunch.” And this is the essence of the moral hazard in health in­sur­ance. Physi­cians and in­sur­ers need to play an im­por­tant and chang­ing role here. As agents of the pa­tient, they have a duty to pro­vide care that yields the best value. This is most ef­fi­ciently done if physi­cians and in­sur­ers share the eco­nomic risk of their ac­tions. This is not pos­si­ble when th­ese eco­nomic con­se­quences are un­known or ignored.

3. What is your po­si­tion on us­ing new busi­ness mod­els such as EHealth, Medi­care Ad­van­tage Plans and ac­count­able care or­ga­ni­za­tions to im­prove ac­cess, qual­ity and lower cost?

E-Health is the umbrella term used to de­scribe telemedici­ne, re­mote video con­fer­enc­ing and the use of per­sonal apps to help pa­tients stay con­nected to their doc­tors and nurses. E-Health needs to be more broadly re­im­bursed. It has demon­strated an abil­ity to be very cost-ef­fi­cient.

Medi­care Ad­van­tage Plans are op­er­ated by pri­vate in­sur­ance com­pa­nies. In this model, the in­surer as­sumes the eco­nomic risk for all care. By fo­cus­ing the pa­tient and their physi­cian on early in­ter­ven­tion in chronic dis­eases and on long-term care needs, the over­all cost of care is mod­er­ated. From th­ese ef­forts, hos­pi­tal­iza­tions, re-ad­mis­sions and the un­nec­es­sary use of emer­gency de­part­ments are be­ing re­duced, re­sult­ing in sig­nif­i­cant sav­ings. Medi­care Ad­van­tage Plans now cover a third of all Medi­care el­i­gi­ble cit­i­zens.

Ac­count­able Care Or­ga­ni­za­tions are a rel­a­tively new busi­ness model. The ACO is de­signed to share the moral hazard of in­sur­ance but in this case with an or­ga­nized group of physi­cians. A group of physi­cians pro­vide all care for a fixed monthly fee. Sav­ings are achieved by hav­ing all care man­aged by pri­mary care physi­cians. Re­fer­rals of pa­tients are made to a se­lect group of spe­cialty physi­cians who pro­vide the great­est value (cost plus clinical out­comes). Ef­forts are made to avoid the use of emer­gency de­part­ments (the most ex­pen­sive site of health care) and by manag­ing the use of hos­pi­tal ad­mis­sions and read­mis­sions. An­nual sav­ings are shared be­tween the fed­eral gov­ern­ment and the providers as a group.

Some ACOs have demon­strated mil­lions of dol­lars in an­nual sav­ings. Shouldn’t we en­cour­age the cre­ation of even more cost-saving ACOs?

At the heart of many of our na­tion’s health care is­sues are pol­icy de­ci­sions that were un­duly in­flu­enced by var­i­ous spe­cial in­ter­est groups. What can the av­er­age Amer­i­can do about all this?

We need to elect rep­re­sen­ta­tives who will take the time to un­der­stand our very com­pli­cated sys­tem and pro­pose changes to im­prove it. As elec­tors, we need to ask them ques­tions about how they pro­pose fix­ing some of the prob­lems. We also need to hold them ac­count­able for their de­ci­sions.

Isn’t that how a rep­re­sen­ta­tive democ­racy is supposed to work?

ED­UARDO CONTRERAS/SAN DIEGO UNION-TRI­BUNE 2017

Dr. Javier Rodriguez, qual­ity im­prove­ment di­rec­tor Sonia Tucker, and qual­ity im­prove­ment spe­cial­ist Navjot Gill (on com­puter screen at right), demon­strate one of the uses (ear exam) of a telemedici­ne cart at the La Maes­tra Com­mu­nity Health Cen­ters Women’s Clinic in San Diego in 2017. De­vices such as this al­low doc­tors to see pa­tients without hav­ing to be in the same phys­i­cal space.

Robert McDon­ald

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