“When Health Policy Gets Personal”

Published on the Health Affairs blog on March 21, 2016.

Like most Health Affairs readers, I spend large parts of my day reading about, thinking about, and advocating for changes to health care.

The flaws with our system are beyond obvious by now: access can be limited or nonexistent; health care costs too much; quality and safety are not guaranteed; care is not well coordinated; and, disparities are stubbornly hard to erase. We compare ourselves to other industrialized nations—usually unfavorably—and wonder why we can’t be more like them, spending less and getting better outcomes. We celebrate mind-boggling scientific and medical advances but lament that they are too expensive and out of reach for many people. I could go on and on. We also have a long list of encouraging remedies and experiments to fix or improve this broken system. Some trendy things come and go, and the acronyms change (or multiply!), but a lot of genuinely promising approaches are being tried. Patient-centered medical homes, for example, have been touted and evaluated as one way to improve care and lower costs. Value-based insurance designs have been championed as a way to encourage more of the “right” kind of care and less of the “wrong” kind. Intensive care management programs are being applied with more precision to patients with complex and costly conditions. Care transition programs can reduce the likelihood of unnecessary readmissions. Payment reforms that put providers at financial risk are on the front burner. Again, I could go on and on. In theory, I support most of these innovations. I have given many speeches and written many pieces about the need for change and advocated for these and other reforms. It is impossible to examine the status quo and not to conclude that we can and must do better. Yet, I’m increasingly finding instances where I am not practicing what I preach when it comes to health care for myself or my family. There is a disconnect between what I do in my day job and what I do in my personal life. Let’s start with my primary care doctor, whom I’ll call Dr. C. Dr. C, who is one of a disappearing breed — a solo practitioner in Manhattan, still in the prime of his career, and with a very busy practice. There is nothing about his practice that resembles a patient-centered medical home or what modern primary care is supposed to look like. When you walk into his office, the first thing you see is a huge wall of paper charts; there is no electronic medical record (EMR) to be found. There is no such thing as a care team because there is no one but him. There is no after-hours access or open access; when he isn’t there, the office is closed. Period. And I’m pretty sure that he relies solely on his own experience and judgment instead of using clinical decision-support tools. Why do I keep going to Dr. C when his practice is so “deficient?” It’s pretty simple: he’s a good doctor. He knows me, my life, and my health history. When I finally get into the exam room after a long stint in the waiting room, he takes his time, and I never feel rushed. I feel like he genuinely cares about me. And without any data to support this, I believe that he provides high-quality care and that I would be in good hands if I did become seriously ill. All those things are more important to me than whether or not he uses an EMR or continues to use paper charts. The same kind of disconnect occurs when it comes to pharmaceuticals. I am pretty healthy and only take some common medications to manage my cholesterol. My insurer (its pharmacy benefits manager, really) has tried everything to keep costs down — they cajole and threaten me into switching to generics. They have tried to force me to use a mail-order pharmacy. They make me and my doctors repeatedly jump through all kinds of hoops—utilization review, medical review, and other layers—before they will approve these drugs. It seems like we need reauthorizations every few months. As a health care wonk, I know these might be considered efficacious and cost-saving best practices. But I really don’t want to be managed by a health plan that only seems interested in putting up barriers and cutting costs. I want to keep my health care between me and my doctor, and I wish they would stop hassling me and trying to deny me medications that are working. One last example of these disconnects: we health care wonks know there is an excessive amount of useless diagnostic testing that drives up costs without providing many benefits, and that might even cause harm. But when it comes to ourselves, isn’t there some comfort in knowing that our provider was “thorough” and checked everything, “just to be sure?” I have to admit that I might want that lab test, x-ray, or MRI just to know we’ve covered the bases. And if my own parent were near the end of life, I’m not sure I wouldn’t want everything possible to be done — even if the wonk in me knows it is to no avail. How should I feel about these disconnects between my life as a health policy professional and my personal life? The harshest judgement would be to say I’m a hypocrite. I prefer to simply conclude that I am human. I’m a firm believer in research and evidence. My work is about taking big picture, systemic views, and forming solutions that work on a large-scale population basis. Yet, I also recognize that health is among the most deeply personal and emotional matters; our hearts and our guts have to be taken into account along with evidence and policy. For those of us in the research and policy arenas, the lesson is clear: remember that policy is not abstract; it is about people. When setting policy, consider what we want for ourselves and our own families, and do unto others accordingly.

“When Government Flexes its Employer Muscle”

Published in the Huffington Post on March 9, 2016

When you think of “government,” what is the first thing that comes to mind? Depending on your point of view, and your politics, your ideas about government may be different from mine, or your sister’s, or your neighbor’s, or your uncle’s. But I’d bet that none of us first thinks, “Employer!” when considering the government.

Except lately, I’ve been thinking a lot about the role of government as an employer, and the creative ideas that local and state governments have experimented with and implemented. It makes sense: local and state governments cover millions of employees and their family members. In fact, state employee health plans are the second-largest area of state health care spending, lagging only state contributions to Medicaid. They have the size and the clout to be in the vanguard when it comes to implementing innovative changes that can promote health, save money, and lead the way for other employers. The private sector could learn a lot from what these employers have been trying out.

For example, the New York City Mayor’s Office recently announced sweeping changes to health care benefits for City employees, designed to help employees make better decisions about their care and ultimately to achieve cost savings. These are important (and long overdue) changes that should be applauded. The City used a data-driven approach to identify opportunities to encourage the use of primary care and preventive services, to improve health outcomes, and lower healthcare costs for municipal employees.

The City has also invested in wellness initiatives designed to keep employees healthy, not just ensure they get care when they’re sick. For example, New York City employees now have access to the National Diabetes Prevention Program, a well-studied initiative that helps participants lose 5-7% of their body weight and decrease their risk of developing diabetes by 50%. The program is also cost-effective, generating savings averaging $129 per participant after three years.

Together, these changes are expected to save more than $3 billion in New York City’s health care spending by the middle of 2018.

New York State is also focusing on making needed changes to its employee health benefits. The New York State Health Insurance Plan covers 1.2 million enrollees and dependents; it is one of the largest group health insurance programs in the country. One priority will be to create incentives for health care providers to reward those that successfully improve the quality of care while reducing health care costs. This approach is aligned with the State’s goal to have 80% of all health care payments made under value-based arrangements by 2020.

Other states have also been active in this area. The California Public Employees’ Retirement System (known as CalPERS, the largest public pension fund in the United States), for example, saw that osteoarthritis was a big cost driver. And the costs were unrelated to the quality of care and outcomes; more expensive treatment didn’t translate to better care. So CalPERS adopted a value-based purchasing model for hip and knee replacement procedures: it limits its own contribution to roughly the median of what these procedures cost in the market. Patients who want to choose a more expensive option may do so, but have to pay the entire difference; this approach is known as “reference pricing.” The introduction of reference pricing for hip and knee replacements led to members paying an average of 30% less per surgery, and achieved $5.5 million in savings in the first two years. Importantly, the change also yielded improvements in health care quality, with participating facilities reporting fewer patient complications and fewer infections.

In Connecticut, a $3.8 billion budget deficit sparked the introduction of a value-based insurance design, focused on both achieving savings and improving health (a running theme!). Its Health Enhancement Program focused on five chronic diseases that were prevalent among State employees and their dependents and identified as key cost drivers: asthma, diabetes, hypertension, high cholesterol, and chronic obstructive pulmonary disease (COPD). The State introduced lower co-pays for the medications required to manage these conditions and eliminated co-pays for related office visits; it also introduced disease education programs to help patients better understand and manage their conditions. The initiative successfully increased the use of preventive services and medication adherence and stemmed the growth in medical and pharmacy costs.

These are just a few examples. And, to be clear, government is not always at the forefront of these types of innovative ideas; sometimes they are what I would call “sleeping giants” that could do much more to develop and implement creative solutions. Private employers all across the country are experimenting with ways to improve their employees’ health and achieve more value for their health care dollars. Companies big and small are implementing proven wellness initiatives like the National Diabetes Prevention Program and testing and evaluating new models of value-based purchasing, disease management, and workplace wellness. The approaches that seem to get the most attention are those in the private sector—mostly large companies like Johnson & Johnson or Pitney Bowes. But as employers design their health plan options and wellness programs, it will also be worthwhile to look to the government employers that are leaders in this area and learn from their example.

“Calling for State Action, Advocates Highlight Immigrant Health Care Dilemma”