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At the intersection of health, health care, and policy.



Last Build Date: Wed, 07 Dec 2016 17:00:46 +0000

 



Five Reasons The ACA Won’t Be Repealed

Wed, 07 Dec 2016 17:00:46 +0000

Since November 8, a chill has descended among individuals nationwide who are involved with or otherwise care about health care. Like sheep herded to their fate, there has been a resignation that the Affordable Care Act (ACA) will be repealed, taking with it coverage for over 23 million people, strong protections for consumers, and innovations in care delivery. But, if you take a closer look, the repeal and replace “two step” is fraught with difficulty, bolder than the ACA itself, and far from certain to succeed. So I think we all need to take a deep breath and refocus on what’s inside the sandwich we are about to be served, and resolve intentionally whether or not we’re going to eat it. I could be wrong. Gutting of the ACA could whistle through the day President Trump is inaugurated, a marvelous, bipartisan replacement plan could swiftly follow, and then everyone will wake up in a few years with at least the same coverage, care quality, and cost containment we have today. But here’s five reasons why I don’t think that’s going to happen: 1. ACA Repeal is Not ACA Repeal Despite the pounding rhetoric shouted from the hilltops for seven years, ACA repeal has never meant repealing the entire law. By my count, there are about 424 sections of the ACA and only a few dozen have really attracted the ire, or even the attention, of opponents. In the manifold replacement plans that have gone beyond a simple statement of “the ACA is repealed,” there is scant reference to the Medicare reforms, workforce provisions, Medicaid program refinements, biosimilars pathway, or hundreds of other items that comprise the bulk of the law. So, just to level set, what we are talking about here is not the entire ACA, it’s a few dozen of the law’s most controversial components. So, what are Republicans actually talking about when they talk about ACA repeal? Ironically, it is the precise parade of horrors that they falsely accused the ACA of being during its passage and since its enactment. The ACA actually expanded coverage for 23 million people and counting; ACA repeal will take those people’s plans away. Literally. The ACA rationalized the health care market for consumers; ACA repeal will immeasurably disrupt it. The ACA required meaningful coverage; ACA repeal will embrace bare bones plans that stick families with most of the bills. Maybe in this post-postmodern world we live in after November 8, facts truly don’t matter. But somewhere somehow I think they do, and will here. 2. The Gordian Knot There’s a reason the ACA is as complicated as it is. It had to be that way to work. The moral nucleus of the law is the insurance market reforms that protect people with serious illnesses like cancer from being denied coverage; older and chronically ill people from being charged impossibly high rates; families from going bankrupt after their costs exceed lifetime coverage limits; dependents up to the age of 26 from walking around without any insurance protection; and so on. The complexity comes in because these universally praised reforms are impossible without sufficient relatively healthy enrollees in the insurance market, thus requiring the mandate to buy insurance and the subsidies to make doing so affordable. Every health care economist on the left or right agrees that if you take that critical mass of enrollees away, the market crumbles, making the consumer protections unsustainable. But that is exactly what the Republican repeal plan would do. While it’s true that the current ACA marketplaces are fragile and in need of refinement, repeal at this time would shatter a burgeoning consumer-driven market that has already endured repeated attempts to undermine its stability. By ripping away cost controls but leaving in place popular consumer protections, Republicans risk pushing the market beyond repair. They know this and, when the time comes, many may have trouble signing off on an approach that imposes irreparable harm on their constituent families. There are vague references to “delaying” implementation of these changes [...]



Taking Stock Of Health Reform: Where We’ve Been, Where We’re Going

Tue, 06 Dec 2016 17:15:21 +0000

Almost from the moment of its inauguration in 2009, the Obama administration has struggled, often against adamant resistance, to enact and implement the Affordable Care Act (ACA). The 2016 election has brought to power opponents of the ACA who will control the presidency, both houses of Congress, and many state houses and governorships. ACA repeal, or “repeal and replace,” seems to be a very real, indeed likely, possibility. It is important, therefore, to take a sober look at what the ACA has achieved in its nearly six years of existence, and what repeal, or repeal and replacement, might look like. This post will describe and assess the ACA in its sixth year, its successes and failures. It will next consider how the new administration might proceed with repealing and replacing it. Finally, it will examine the provisions that the new Congress and administration may adopt to try to replace the ACA and assess how they might improve on or undermine the ACA’s accomplishments. This assessment will focus on the effects of the ACA and its likely replacements on accessibility and affordability. Other measures could also be used to evaluate the success of health system reform, such as effects on the total cost of the health care system or the quality of the health care it provides. Success could also be judged by the ramifications of health reform on individual choice, or freedom, or on the economy as a whole. I choose to focus on accessibility and affordability because I believe that these are areas where government intervention in terms of financing or regulation—or most likely both—is most essential. There are two facts about health care that are beyond debate. First, in any given year the vast majority of health care costs are attributable to a small minority of the population and the vast majority of people spend comparatively little on health care. In a given year, the most costly 5 percent of the population accounts for almost 50 percent of health care spending, while the least costly 50 percent accounts for less than 3 percent of spending. Private insurance can move resources from those who cost less to those who cost more, but there are limits to the extent that it will do so in an unregulated market (assuming private insurance can even exist in an unregulated market). Absent regulatory requirements, private insurers will exclude high-cost individuals and pre-existing conditions from coverage and will set premiums (and cost sharing) at rates that are actuarially accurate given whatever the insurer can predict the likely cost will be to cover the applicant and dependents, considering health status, age, gender, location, and other factors. Second, the distribution of income and wealth are also sharply skewed in the United States. Given the high cost of American health care, many Americans could not afford even the most basic health care services without government assistance. The vast majority of Americans currently receive assistance for purchasing health care or health coverage not just through the marketplaces, but also through government programs such as Medicare or Medicaid and through tax subsidies for employer-sponsored coverage. When analyzing affordability of health coverage, it is important to consider out-of-pocket costs as well as premiums. The premium on a catastrophic policy will obviously be less expensive than the premium for a low-deductible policy, but the coverage may be worthless to an individual who cannot afford to pay for the cost sharing imposed by the policy unless that cost sharing is adequately subsidized by the government via direct payments, contributions to a Health Savings Account (HSA), or other mechanism. The ACA’s Structure Access Provisions The ACA included a number of measures to ensure access to health care for persons with high-cost medical conditions. First, it required insurers to offer coverage to all applicants and to guarantee renewal for all covered individuals. Second, health status underwriting was outlawed in all insurance markets. P[...]



Rewarding Provider Performance: Ten Years In

Tue, 06 Dec 2016 15:30:44 +0000

Editor’s note: When we read Sharon Long and colleagues’ retrospective on Massachusetts health reform at 10 years in the September issue of Health Affairs we were reminded just what a busy year 2006 was for health policy writ large (in addition to wondering ‘Has it been that long already?’). Now a decade later, we think there’s something to be gained from looking back on the impact and reach of some of the most significant policies implemented that year. With that in mind, Health Affairs Blog invited a handful of policy makers and researchers to reflect on some of these major milestones, share lessons learned, and discuss how our world has changed since then. Visit the Blog for more posts in this occasional series. Ten years ago, the Institute of Medicine (now the National Academy of Medicine) released a report “Rewarding Provider Performance: Aligning Incentives in Medicare” reflecting the work of an IOM subcommittee that Robert Reischauer and I co-chaired. When the subcommittee was organized, various professional groups had already recognized Medicare incentives’ lack of alignment between clinicians and institutions and the lack of focus on individual outcomes. What was still relatively new and as yet untested was the development of payment strategies that would focus on outcomes and performance rather than on inputs. It was also clear that the country would need to develop new metrics that could be used to support payment reform. Ten years later, the country is further along this path, but we are still relatively early in the process. Many of the principles articulated in 2006 remain our focus for change in 2016: encouraging rapid performance improvement, supporting innovative change, promoting better outcomes, fostering care coordination, and rewarding both provider improvement as well as provider achievement. Persistent Challenges A lot of work has been undertaken to transform the system from an input-based reimbursement system that encourages volume to an outcomes-based reimbursement system that rewards value. Yet many of the challenges identified 10 years ago remain unresolved today. To be sure, some of the basics have improved. A decade ago, the committee advocated offering incentives to providers to collect and submit data. That strategy has been successfully used to encourage physician reporting as part of the Physician Quality Reporting System (PQRS) and will continue to be used as the Medicare Access and CHIP Reauthorization Act’s rules—part of which subsumes the PQRS—take effect in 2017. Under the final rule released this fall, physicians providing at least some data as part of the law’s Merit-based Payment Incentive System will be protected from a reduction in fees in 2019. CMS has also adopted a number of value-based programs, many of which were part of the Affordable Care Act (ACA) legislation. Four were part of an initial set: the hospital value-based purchasing program, hospital readmission reduction program, the physician value-based modifier, and the hospital-acquired condition program. In addition, the Centers for Medicare and Medicaid Services (CMS) has added an end-stage renal disease quality initiative, a skilled nursing facility value-based program, and a home health value-based program. The challenge for all of these value-based programs is whether they can change behavior when the base payment still dominates the total payment. For example, under the hospital value-based purchasing program, which was structured to be revenue-neutral and was originally implemented in 2013, hospitals will be receiving payment in fiscal year 2016 based on performance from 2014. What is more, the maximum penalty is limited to 1.75 percent of Medicare payments and bonuses will be limited to a maximum of approximately 3 percent. Some 3,000 hospitals are receiving penalties or bonuses for 2016 and according to a Government Accountability Office (GAO) report, they amount to less than 0.5 percent of applicable Medicare payment. Not su[...]



Health Affairs Issue: Oral Health And More

Mon, 05 Dec 2016 21:00:14 +0000

The December issue of Health Affairs explores the state of oral health. Editor-in-chief Alan Weil writes that “the divide between dental care and medical care is vast, has significant consequences for patients, and is entirely of our own making.” More Financial Barriers to Dental Care While the Affordable Care Act (ACA) has brought about a decline in the number of nonelderly adult Americans without health insurance, a much higher share of Americans lack dental insurance. Marko Vujicic of the American Dental Association’s Health Policy Institute and coauthors examined data about financial barriers to care from the 2014 National Health Interview Survey, comparing the responses of nonelderly adults with children and seniors. According to the data, 12.8 percent of nonelderly US adults reported forgoing dental care because of cost, compared to 4.3 percent of children and 7.2 percent of seniors 65 and older. Community Water Fluoridation In 2001 the Centers for Disease Control and Prevention (CDC) released a study of US community water fluoridation program costs and savings, which found that reductions in tooth decay associated with water fluoridation resulted in significant cost savings (that is, savings exceeded costs). Joan O’Connell of the Colorado School of Public Health and coauthors developed a model to update these findings using more recent information on fluoridation costs, the incidence of tooth decay, and treatment costs. According to the CDC, more than 211 million US residents had access to fluoridated water in 2013. The authors estimated the cost to fluoridate the water in that year to be $324 million, with savings due to reductions in tooth decay of $6.469 billion, meaning a 20.0 return on investment — $20 saved for each dollar spent. A related study in the issue: School-Based Dental Sealant Programs Prevent Cavities And Are Cost-Effective by Susan Griffin of the Centers for Disease Control and Prevention and coauthors. Young African-American Adults May Now Have Better Oral Health Healthy tooth development starts early in life — even before birth. Brandy Lipton of the Agency for Healthcare Research and Quality and coauthors examined the effects of a historic expansion in Medicaid eligibility for infants and pregnant women in the 1980s and 1990s on the adult oral health of those who gained eligibility as infants. Using data from several years of Behavioral Risk Factor Surveillance System (BRFSS) surveys and a sample of adults born between 1979 and 1991, the authors found that the nearly 28-percentage-point increase in Medicaid eligibility among non-Hispanic black pregnant women and infants during this period was linked to better oral health among black young adults, with a significant decrease (about 8–10 percentage points) in the likelihood of the loss of permanent teeth. DATAWATCH: The Financial Burdens of High-Deductible Plans The increasing prevalence of high-deductible employer-sponsored plans raises important policy questions regarding out-of-pocket spending burdens on low-income families. Salam Abdus and coauthors at the Agency for Healthcare Research and Quality reviewed data from the 2011–13 Medical Expenditure Panel Surveys (MEPS) to determine the financial impact of employer-sponsored insurance by income group and deductible level. The authors noted that regardless of the deductible level, people in the low-income group (with incomes below 250 percent of the federal poverty level) were far more likely to have paid over 20 percent of their after-tax income on premiums and cost sharing, compared to those in higher-income groups. Also of interest in the December issue: Many Mobile Health Apps Target High-Need, High-Cost Populations, But Gaps Remain by Karandeep Singh of the University of Michigan Medical School and coauthors. The December issue is supported by The California Wellness Foundation, the DentaQuest Foundation, the American Dental Education Association, the REACH Healthcare Foundat[...]



Court Stays Cost-Sharing Reduction Payment Case, Giving Control To New Administration And Congress (Updated)

Mon, 05 Dec 2016 19:42:01 +0000

December 7 Update Twelve Million Unknowingly Eligible For Premium Tax Credits On December 5, the HHS Assistance Secretary for Planning and Evaluation (ASPE) released a blog post stating that almost 12 million Americans may be eligible for financial assistance purchasing health insurance in the marketplaces but not be aware of this fact. The blog post reports that 8.8 million persons currently receive advance premium tax credits (APTC) in the 38 states served by HealthCare.gov in 2016. An additional 286,000 consumers who received coverage through Healthcare.gov in 2016 without APTC may be eligible for assistance for 2017. Eligibility for APTC turns on whether or not the premium of the relevant benchmark plan exceeds a certain percentage of a consumer’s household income, and with 2017 premium increases more consumers will have to pay premiums exceeding these thresholds and will become eligible for APTC. ASPE further estimates that 2.5 million individuals who currently purchase coverage in the individual market outside of the marketplaces would be eligible for APTC if they instead purchased coverage through the marketplaces. Finally, ASPE believes that 9 million uninsured Americans, 84 percent of the marketplace-eligible uninsured, earn incomes indicating that they may be eligible for financial assistance. (Although an undetermined number of these would be ineligible because they have affordable employer coverage). The blog post includes state-by-state data on potential APTC eligibility for HealthCare.gov enrollees for 2017. Agent And Broker Marketplace Questions On December 2, 2016, CMS released at its REGTAP.info website (registration required) a series of FAQs regarding agents and brokers in HeathCare.gov. The FAQs clarify that if consumers who were enrolled in marketplace coverage through agents or brokers update their marketplace application information or renew coverage through the marketplace, the National Producer Number of the agent or broker will remain with the application unless the consumer affirmatively changes or removes it. If a consumer who was enrolled in a plan that is no longer offered through the marketplace is auto-reenrolled into a different plan, however, the reenrollment will be assigned according to the marketplace auto-reenrollment crosswalk hierarchy and will not take into account whether the new insurer works with or compensates agents and brokers. The FAQs emphasize again that the marketplace does not require insurers to compensate agents and brokers and that compensation arrangements depend strictly on agreements between the insurers and the brokers and agents. The FAQs reiterate, however, that insurers must pay agents and brokers the same compensation for selling a qualified health plan inside or outside the marketplace. A number of insurers have ceased paying commissions to agents and brokers for marketplace enrollments and agents and brokers are understandably unhappy. LifeHealthPro reports that 61,263 agents and brokers had registered for marketplace participation as of November 8, 10 percent fewer than last year, but that registration between November 8 and November 28 was down 60 percent from 2015. It reports further that 47 web brokers remain with Healthcare.gov as of November 14, down from a peak of 82 in March of this year. CMS maintains lists of marketplace-registered agents and brokers and web-brokers. Original Post On December 5, 2016, the Circuit Court of Appeals for the District of Columbia acceded to the request of the House of Representatives and stayed further proceedings in House v. Burwell pending further motions by the parties, due by February 21, 2017. In this case, the House of Representatives claims that government payments to insurers to reimburse them for reducing cost sharing for silver plan marketplace enrollees with incomes not exceeding 250 percent of the poverty level are illegal because Congress has not appropriated the funds for those payments. The ACA[...]



How NashvilleHealth Is Maximizing Community Population Health

Mon, 05 Dec 2016 17:00:53 +0000

How can Main Street, America, move the needle in a city’s population health and wellbeing? It begins with a solid, organizational structure built for the long term. I fondly call my hometown, Nashville, the “Silicon Valley of Health Services.” With 18 publicly traded national health care companies headquartered here with annual global health care revenues of over $70 billion, our city takes health seriously. One in 10 workers in the Nashville metro area are health care providers, nurses, or health aides. Even more work in the broader health sector, such as health management, financial, and legal roles. We have two outstanding medical schools, six schools of nursing, a dental school, and two schools of pharmacy. Our city is in the business of providing multiple health services to every state in the country. Here is the cruel irony. When you compare us to similar cities, the health of Nashvillians is poor. We smoke at rates higher than Charlotte. We have blood pressure rates that exceed those in Austin. Our obesity rate surpasses Cincinnati’s. Our infant mortality rates are not even competitive. Our babies are more likely to die in their first year of life than in countries like Croatia, Serbia, and Qatar. How can that possibly be? One of the things they didn’t teach me in medical school is that health services delivered accounts for only 10 to 15 percent of a population’s health status. We can build the best hospitals, provide the richest health plans, and I can be the best heart surgeon possible, but behavior and how and where people live, eat, work, and play have a far greater impact on an individual’s health. Discover your community’s health I first learned how poorly my city compared to others when I ran across the Robert Wood Johnson Foundation’s annual County Health Rankings. It was a rude wake up call. As a doctor and one familiar with our city’s reputation as a health services capital, I proudly represented Nashville as a senator in Washington. We could not possibly be that bad. But we were. It was clear that Nashville’s recent national publicity as an “it city,” exploding with new restaurants and creative music and attracting a huge influx of dynamic, young people, would not be sustained for long without a solid foundation of good health. So I along with a handful of other interested citizens set out to determine what could be done to change the trajectory of a city’s health equity and its people’s well-being. And this sparked an idea that has become a robust community initiative to build a countywide, collaborative health movement. It’s called NashvilleHealth. But we didn’t get to this point overnight. First, we began investigating other cities’ population health initiatives to see what we might adopt. We sought advice from national leaders in the field of regional health transformation. And then, to learn about the many existing, but too often siloed, efforts underway to address Nashville’s health needs, we intensively engaged our local community. In fall 2014, we convened a town hall to discuss intervention options. From this early groundwork, it became clear that Nashville was unique (as headquarters to the many national health care chains, for example) and would best benefit from its own Nashville-developed solution. High level leadership, comprehensive local engagement, and a clear mission Highly visible and effective CEO leadership would be fundamental. In the summer of 2015, we were fortunate to have the experienced and highly respected former head of the Nashville Health Care Council, Caroline Young, step into the role of Executive Director for NashvilleHealth. She and a few volunteers began a formal listening tour, and in a little over a year, a small and nimble NashvilleHealth team had held over 200 community meetings uncovering issues, interests, challenges and success stories from a vast array of local entities and [...]



Making The Case For States To Reduce Out-Of-Network Charges

Mon, 05 Dec 2016 14:00:34 +0000

There has been increased attention to unexpected bills due to out-of-network charges among the commercially insured population. For example, a recent Brookings report examined where and how “surprise medical bills” can occur in context of U.S. health care. Zack Cooper and Fiona Scott Morton, in a just-published New England Journal of Medicine article examined out-of-network emergency-physician bills from in-network hospitals using claims data from a large commercial insurer. The authors found that even when insureds went to an in-network hospital, they received a bill from an out-of-network provider 22 percent of the time. Cooper and Morton also reported that out-of-network emergency department (ED) physicians charged an average of almost 800 percent of Medicare so the “surprise bill” is not a trivial difference. Some states have already acted to protect their residents. California enacted legislation protecting patients who receive out-of-network non-emergency care at an in-network facility. Under the legislation signed by Governor Brown, health plans would pay non-network physicians the plan’s average contracted rate or 125 percent of the Medicare rate, whichever is greater. Californians were already protected from balance billing in emergency situations. Florida passed similar legislation in 2016, which prohibits billing for out-of-network charges for emergency services and billing for out-of-network charges when the services were provided at an in-network facility and the patient did not have a choice of an in-network provider. In New Jersey, Assembly Bill No. 1952, which is intended to protect consumers from surprise medical bills, is now under consideration. The proposed legislation places limits on out-of-network charges when emergency services are provided or the out-of-network services are “inadvertent.” Inadvertent services are defined as services that arise when an individual utilizes an in-network facility for covered services and in-network services are not available. While there are existing consumer protections in New Jersey, some versions of the bill offer new protections to self-funded plans. If the provider and insurer or individual cannot agree on a reimbursement rate for these services within 30 days after the insurer is billed for the service, any party may initiate binding arbitration. The arbitrator can either find that the requested fee is reasonable and order payment or the arbitrator can fix the amount owing within a range of 100 – 250 percent of Medicare. Evidence for State Action in New Jersey While New Jersey contemplates legislation to address surprises medical bills, the RAND Corporation last week released a report, sponsored by Carepoint Health Inc. a for-profit hospital system operating in New Jersey, analyzing the proposed New Jersey legislation. RAND assumed that “revenues from involuntary out-of-network services accounted for less than 20 percent of commercial revenues but almost 40 percent of profits from treating the commercially insured.” In addition, they concluded that if a limit of between 90 and 200 percent of Medicare rates for involuntary out-of-network hospital care was imposed, between 48 and 70 percent of the hospitals in New Jersey would operate at a loss. On a first pass, the RAND study results are troubling, suggesting that hospitals, at least in New Jersey, are using out-of-network billing practice to remain solvent. However, as with almost all aspects of the U.S. health care system, the implications are more nuanced. Although RAND recognized that there are 71 hospitals in the state, the analysis was conducted by Metropolitan Statistical Area (MSA) because the Truven dataset used for their analysis does not contain a hospital identifier. A hospital-level analysis provides important insight into the source of out-of-network charges and implications for hospitals. The Cooper and Morton r[...]



National Health Spending Grows Faster In 2015

Fri, 02 Dec 2016 19:05:41 +0000

A new analysis from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS), published as a Web First by Health Affairs, estimates that in 2015 health care spending in the United States grew at a rate of 5.8 percent and reached $3.2 trillion, or $9,990 per person. In 2014 spending increased 5.3 percent, which followed five consecutive years of historically low growth from 2009 to 2013. Faster growth in 2014 and 2015 occurred as Affordable Care Act (ACA) provisions expanded coverage for individuals through Marketplace plans and the Medicaid program. Share of Gross Domestic Product Increases to 17.8 Percent Health spending’s share of the nation’s gross domestic product (GDP) was 17.8 percent in 2015, up from 17.4 percent in 2014. Coverage expansions that began in 2014 as a result of the ACA helped increase the percentage of the population with health insurance from 86.0 percent in 2013 to 90.9 percent in 2015.  This expansion of coverage continued to affect health spending growth in 2015. Faster growth in total health care spending was primarily due to accelerated growth in spending for private health insurance (7.2 percent), hospital care (5.6 percent), and physician and clinical services (6.3 percent). While Medicaid spending and retail prescription drug spending grew at a slower rate than in 2014, continued strong growth in both contributed to overall health care spending growth in 2015. On a per capita basis, national health spending grew at 5.0 percent, reaching $9,990 in 2015. Changes in the age and sex mix of the population accounted for 0.6 percent of the growth in per capita health spending. Increases in medical prices and residual use and intensity of health care goods and services accounted for 1.2 percent and 3.2 percent of the growth, respectively. Health Spending Projected to Increase “Over the last fifty-five years, the largest increases in health spending’s share of the US economy have typically occurred around periods of economic recession,” said Anne B. Martin, an economist in the CMS Office of the Actuary and first author of the Health Affairs article. “While the 2014 and 2015 increases occurred more than five years after the nation’s last recession ended, they coincided with 9.7 million individuals gaining private health insurance coverage and 10.3 million more people enrolling in Medicaid coverage. An additional contributing factor is the rapid growth in retail prescription drug spending.” While 2014–15 is unique given the significant changes in health coverage that have taken place, health spending is projected to increase as a share of the overall economy in the decade ahead. It will be influenced by the aging of the population, changing economic conditions, and faster medical price growth. This study will also appear in the January 2017 issue of Health Affairs. [...]



Barriers To Change: The View From Berlin

Fri, 02 Dec 2016 16:43:32 +0000

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For the past two years, Health Affairs has published blog posts arising from the Center for Healthcare Management’s forums, held in Berlin. These events are unlike a typical conference — more conversation than presentation, and more participation by various actors in the health care sector than discussion of a single topic. An excellent summary of the entire event can be found here.

Why Is Change So Slow?

The same question bedeviled the attendees as challenges all who are interested in improvement in the health sector: If the distance between the value we obtain from our health care investment and what we receive for that investment is so apparent, why is the system so resistant to change?

In remarks at the forum, Sherry Glied, Dean of the NYU Wagner School of Public Service, suggested three barriers: focus, politics, and inertia. Her blog post presents some of her thoughts regarding focus. In essence, the concentration of high medical costs among a very small segment of the population makes risk avoidance a viable business model when compared to the difficult work of actually redesigning how health care is delivered so it is more efficient. While she acknowledges steps that have been taken to reduce the rewards for avoiding risk, she argues that additional steps are needed to help shift the focus.

Bearing Risk As A Motivation For Change

Bruce Fried had a more optimistic perspective on risk, arguing that the evolution of payment toward value-based methods, while very complex for health care organizations to handle, is the largest driver of change in the health care system today. Fried describes this view.

Frank Maddux discussed that very challenge for an organization transitioning from providing dialysis to caring for the entire person with kidney disease.

Other participants in the forum examined the problem of lack of focus from a different perspective. Many attendees were from organizations that have made significant efforts to improve care, only to find that the business model doesn’t support the changes they have put into place. No matter how much policymakers and payers say they want the delivery system to focus on improvement, it’s hard to do so when their payment policies don’t align with their words.

The Role of Politics

Glied’s second point was about politics — a particularly interesting topic at a global forum where the political systems and imperatives were so variable among the attendees. Yet, the theme of politics as an impediment to change was always there. For example, Peter Homberg described how the regulatory regime in Germany causes delays in introduction of pharmaceuticals due to that country’s pricing policies.

Liz Fowler noted that the move toward value may be global, but how value is defined varies substantially around the world.

No matter the country, those who are delivering care have a stake in continuing to do things pretty much the same way. Whether it is through protecting existing payment streams or challenging regulations that implement a change, the health care sector seems able to use the political process to impede the pace of delivery system change.

The Problem of Inertia

And then there is inertia. From one perspective, inertia is simply the sum of a lack of focus and entrenched politics. In this view, inertia is the embodiment of resistance to change. But Martine Bellanger suggested another view of inertia: as the source of unhappiness in health care. Unhappiness by workers, trapped in organizations, burdened by rules and regulations, saps the energy needed to effect real change.

A Problem of Management?

If politicians say they want better value, payment policies are shifting toward value, and health professionals want to provide value, why are we moving so slowly? Perhaps because we rely so heavily on management as the mechanism for translating these incentives into action. Consider the growth of physicians and administrators in the US from 1970 to 2009, shown here.

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Returning to Sherry Glied’s remarks and suggestions, it strikes the external spectator that the system might have created its own slack by subscribing to complex management approaches, refining and implementing incentives without much evidence of added patient value. As clinicians view themselves as subject to management controls, they lose their sense of purpose.

In the end, change occurs because motivated and creative people push themselves and their organizations to do something different from what is expected of them. Policies and politics lag change; they don’t lead it. The challenge for health care is to liberate and energize those with the vision and resources to make improvements and hope that their leadership will change the context for the rest of the system’s actors, who will follow, hopefully happily, as their view of what is possible is reshaped by the vision of the leaders.

It remains to be seen whether proper and purposeful management will be aligned with medical care of the 21st century. The system’s ability to exist and persist as it is seems to be the most powerful force opposing change.