As our new president has said, health care is complicated. Republicans call for Obamacare’s repeal, but are hard-pressed to come up with a workable alternative. Democrats recommend improving Obamacare, but are largely silent as to how they would do that. Americans are caught in the middle of this apparent health-care quagmire. But for America to flourish as a nation, a solution must be found.
To start, we must frame the issues accurately. The American health-care system suffers from three problems: lack of access to care; the high costs of care; and poor quality of care.
The Affordable Care Act (Obamacare) focused on providing more access to care, by enabling more people to purchase insurance, but didn’t significantly address cost or quality issues. The Republican health plan, comically named the Better Care Reconciliation Act, worsens access issues (a huge number of people would lose insurance), makes health care more expensive for many, and doesn’t address quality.
The key to a fix are solutions to all three issues, with cost being the crux. We must successfully lower the costs of care for the money to provide more access to care. Improving the quality of care should contribute to lowering costs, as well.
Lowering the Costs of Medical Care
By some estimates, thirty cents on every US health-care dollar goes towards administration, double the amount spent in other nations. It represents a very obvious and necessary area for cost reductions.
Health-care professionals today fight less against disease, and more against a sea of red tape. Getting paid for a simple office visit is more complicated than the visit itself. And insurance company prior authorization processes create hours of work just for patients to obtain simple tests or prescriptions. Getting care depends not on a clinician’s skills, but their knowledge of (and the time for) the workarounds made necessary by this byzantine system. It is massively wasteful and distracting.
All new or planned administrative programs should be put on hold until true administrative simplification takes place. The slate must be wiped clean so that health-care professionals can again focus on providing and improving patient care. To begin with, all aspects of getting paid for medical care should be dramatically simplified. In fact, most medical billing can be entirely replaced by point-of-care payment cards.
One of the most powerful and under-appreciated opportunities for health-care cost reductions is preventable chronic disease, which accounts for roughly eighty-five percent of all medical expenditures in the US. Healthy lifestyles have been shown to reduce illness by eighty to ninety percent. Wellness must be an integral part of American life—it is a national economic imperative and key to solving our health-care puzzle. School fitness and healthy meal programs must become mandatory, but even more important, similar approaches must be applied to the workplace. One of the main drivers of obesity and preventable disease is the expectation that working adults, out of the house early and home late, will find time outside of work hours to eat healthy and to exercise. Healthy eating and fitness activities must become part of the work day. Something as simple as structured physical activity for five minutes on every work hour would change the health of the nation.
Improving the Quality of Care
Current efforts to improve the quality of health care in the US center around forms of “value-based” pay (as opposed to the current volume-based, or fee-for-service pay structure), where the results of quality-of-care clinical data are used to generate payment bonuses or penalties. Such approaches make little sense in the current health-care environment.
First of all, using current electronic health record (EHR) technology, collecting and reporting such data can be difficult and labor intensive. In addition, the administrative overkill previously discussed, hard-to-use EHRs (the rule, not the exception), and inadequate coverage for many aspects of even basic care often conspire to impede quality. We hold clinicians responsible for quality in a system that works against it.
Also, value-based approaches that employ penalties punish physicians who take care of the most challenging patients, often for things beyond the physician’s control, such as lack of insurance coverage, income level, and lifestyle habits. This is just a bad idea that will discourage many physicians from taking care of the patients who need the most help.
I agree that we should work towards ways to balance volume and quality in paying for health care. But the American health-care system is not at a point where it can support such approaches. That is likely why studies of value-based payment yield such limited results.
A better approach to improving care is what I refer to as the building blocks of health-care system success. The first is administrative simplification and removal of barriers to care, such as the onerous prior authorization requirements mentioned previously. Clinical staff must be freed from hours of such wasted time if we expect them to refocus on patients and improving quality.
The second such building block is improved EHR technology. Advanced, usable EHRs hold the key to new and superior ways to deliver care, but so far have almost completely failed to deliver on their great promise. The federal government should coordinate an effort to find or create the first great, usable EHR, and distribute it, at low or no cost, to anyone who wants it. An EHR “public option” of sorts would do more than any other one thing to advance health care capabilities in this nation.
Every American can have affordable, high quality health care. Health care professionals should work in an environment that enables and encourages great care. But only if we successfully address all the issues—access to care, cost of cost of care, and quality of care—will we successfully fix American health care once and for all.