The U. S. health care system continues to face significant challenges. The political environment remains divided on how best to invest in changes that will make health care affordable, high quality and accessible for the people it serves. Advancing a responsible policy environment includes addressing shortfalls in the quality and efficiency of care that lead to higher costs and to poor health outcomes. After all, a healthy nation is a productive nation.
Over the years, the federal government has made multiple sweeping health care reforms, from establishing Medicare and Medicaid in 1965 to the Affordable Care Act in 2010, in attempts to address coverage, costs and quality. Now, sustaining our health care system depends on driving down costs. For health care organizations, investments in the smart and innovative use of health information technology (IT) are expected to play a major part in cost reduction. With over $37 billion in HITECH payments for Promoting Interoperability programs, the U.S. enjoys almost ubiquitous adoption of electronic health records (EHRs) among eligible hospitals and office-based physicians. We should be at the point where we can maximize secondary order effects from EHRs, including advanced clinical decision support, research, improved diagnostics and patient outcomes.
The role of government
While there is little disagreement among policymakers on the importance of driving efficiency in health care, a key area of debate is the relative roles of the government and the market in enabling or creating that efficiency. Democrats advocate for "Medicare for All," while Republicans argue for market-driven health care with fewer government mandates on employers, insurers, providers and consumers. Similar to deregulation in the airline and trucking industries, the presupposition is that deregulated, market-driven health care can lead to greater competition, lower costs and more price transparency.
The tricky part is accounting for the dominating presence the government has in today's health care. In addition to the U.S. federal government's responsibilities as protector of its citizens, economy and public service, it is also both the largest provider of health care and the largest payer. Governmentsponsored plans and medical assistance such as Medicare, Medicaid, Children's Health Insurance Program (CHIP) and military health care pay for health services for 37.3 percent of Americans. Health care spending by federal, state, tribal, local and territorial governments is greater than that of private businesses, households and other private payers. As such, our governments have an obligation to reduce inefficiencies in their own spending. Centers for Medicare & Medicaid Services (CMS) administrator Seema Verma's July 19 blog post reaffirms the current administration's commitment to addressing inefficiencies and reforming the health system.
"We believe at CMS that a major cause for the cost inefficiency of health care is attributable to a failure in the past to make the system about the patient and for the patient. It is the system that has become the centerpiece of policy debates, and it is the system that has become more about sustaining itself than serving patients. If the patient truly is what our health care system seeks to serve, then the patient must be the focal point of all policies and private industry decision-making."
What are policy levers, and where do we need them?
In an effort to steer health care policy toward a focus on the patient, the federal government has many options to consider in the form of policy levers. Policy levers can be any form of incentive, penalty or mandate used to effectuate change. In the health IT world, we see many types of policies in support of health IT adoption, use or interoperability. The federal government's collective mission for health IT is "to improve the health and well-being of individuals and communities through health information that is available when and where it matters most." Navigating the current environment of regulations is complex, and some argue government actions and policies to date have created unintentional, untenable consequences. In the midst of an administration focused on deregulation and deferential to the private market, what can we expect from our current government?
We continue to see significant strides toward provider-toprovider data exchange as the Office of the National Coordinator of Health IT meets its obligation under the 21st Century Cures Act to provide rules on Information Blocking as well as establishing a national framework for interoperability (proposed as the Trusted Exchange Framework and Common Agreement, or TEFCA). The stakes are high for suppliers and providers that block the exchange of data, from decertification of EHR solutions that don't share data to potential anticompetitive behavior allegations to possible violations of the health care trifecta legal heavy hitters: the Anti-Kickback statute, the Stark Law and the False Claims Act.
Empowering the consumer
One mechanism CMS will leverage to accomplish the government's goals to maximize value, safety and quality in the health care system is to advance the ability for patients to access, use and control their own data, as well as drive data exchange, through an initiative called MyHealthEData. Consumers with strong incentives to save money represent a powerful lever that could reduce prices and increase quality. Efforts are underway to empower consumers and free data for the patient to mitigate his or her own data exchange, with the support of CMS's Blue Button 2.0 and continued implementation of application programming interfaces (APIs) accessed by apps of the consumer's choice, such as through Apple's HealthKit. This study in behavioral economics hypothesizes consumers will choose their provider in part based on the provider's ability to support his or her desired technology needs, which will in turn incentivize providers to support smart technology capabilities.
Health care is moving away from fee-for-service (FFS) and toward alternative payment models (APMs) and valuebased care (VBC), which should encourage providers to exchange data in order to maximize the full effect of these payment models. However, FFS can still play an important role as a vehicle for encouraging behavior. For example, CMS offers an FFS payment to ambulatory providers under the Physician Fee Schedule to receive and review information for their patients after a hospital encounter, which could be adopted for other providers and facilities to incentivize and encourage desired behavior.
The evolution of Medicare Advantage (MA) will also contribute to the move toward value-based care and increased efficiency, as CMS expands coverage to non-traditional services designed to address social determinants of health. In a recently issued final rule, CMS gave MA plans the flexibility to offer non-traditional benefits such as home visits, nutritional support and ride sharing services. By giving payers discretion to cover a wider array of services, CMS can pave a way toward increased population health management. With MA enrollment predicted to comprise half of all Medicare enrollment by 2025, the new rule could further advance the VBC model.
Digitization of EHR data continues to grow, and we will continue to see innovations in second order value from that digitization, along with issues of data access rights, privacy and other related policies that must be tackled. These innovations will ultimately bridge data and business models from what were previously non-health care industries — financial, consumer, social and so on – to continue breaking down information silos and supporting the exchange of data.
Talk of overhauling the Health Insurance Portability and Accountability Act (HIPAA), addressing data governance and access issues across business models, harmonizing a patchwork of laws at the state level, as well as understanding the effects of global efforts such as General Data Protection Regulation (GDPR), will certainly coalesce into government action in the near future.
In this world nothing is certain, except death and taxes … and continued government-driven changes to the U.S. health care market. Underlying the differences in political philosophies is the fundamental agreement that the current system is broken, and it is worth fixing.