Health Care Reform: The Blurred Lines Between Productivity and Politics

There is universal agreement that we need to find ways to restrain health care costs in order to make our system affordable for governments, consumers and employers and achieve long-term sustainability. In searching for solutions, it is critically important that we recognize the difference between genuine cost containment and what one could call "belt tightening" in and around Capitol Hill.

By developing innovative approaches to health care delivery and using the tools and technologies already at our disposal, it is possible to keep people well to reduce the need for lengthy hospitalizations and prevent readmissions and expensive interventions. Right now in Washington the focus is too often on hitting arbitrary, short-term budget targets and demonstrating fiscal conservatism within the prism of the Congressional Budget Office's 10-year budget window. That can mean a counterproductive trade-off -- saving pennies today with policies that will drive increased costs tomorrow.

To a degree, that's the approach we're seeing in the proposed regulations establishing essential health benefits that -- under the Affordable Care Act -- all participating health insurers must cover. The concept of having a basic, minimum set of benefits is important in protecting population health. It's the details, though, that determine whether we're going to be keeping Americans well, or risking greater incidences of illness by taking unwise steps to shave short-term costs.

An example is found in the provision affecting insurance coverage of prescription drugs for some of our most seriously ill and at-risk patients. According to the proposed regulations, in certain therapeutic categories affecting patients with cancer, epilepsy, HIV/AIDS, mental illness and other serious conditions, insurers will be allowed to limit coverage to as few as two prescription drugs. The motivation is apparent --- save money by limiting patient access to those medications that are the least costly.

But here's where cost-cutting as it's currently being approached by legislators and regulators, runs up against real-world health care. No bureaucracy, no regulation can make a medicine effectively treat a patient's condition. Simply put, our genetic makeups and our body chemistries are not identical. A drug that works well in treating one patient's symptoms may be ineffective in another, or even cause unforeseen side effects. That's why physicians often have to prescribe different medications to their patients until they find the one that gets optimal results.

By so severely limiting insurance coverage of prescription drugs, the federal government is essentially tying the hands of doctors and patients in seeking the best available treatment.

This is the wrong way to curb health care spending increases. Yes, we can save a few dollars today by limiting access to medicines, but if cancer patients and people living with HIV/AIDS or struggling with depression or schizophrenia can't afford the drugs they need, there is a heavy price to be paid in terms of increased hospital admissions, emergency room visits, unemployment and loss of productivity.

Cost containment, if done correctly, will focus on wellness, disease prevention and keeping chronically ill patients healthier. The fact is that pharmaceutical spending represents a very small portion of overall health care costs in the United States and effective use of medications remains one of our essential tools in combating the chronic diseases that eat up 80 cents of every health care dollar we spend in this country.

A good model to follow is the Medicare Part D prescription drug program, which gives senior citizens a wide range of access to the medicines their doctors prescribe. A study published in the Journal of the American Medical Association found that Medicare is saving $1,200 per year per patient in reduced hospital and skilled nursing costs because Part D beneficiaries are staying healthier.

There's still time to do Affordable Care Act implementation right. The key is in prioritizing real health and real long-term savings over making today's numbers add up to CBO's satisfaction.

Kenneth Thorpe, Ph. D., is the Chairman of The Partnership to Fight Chronic Disease; Professor and Chair at the Rollins School of Public Health at Emory University; Former Deputy Assistant Secretary for the U.S. Department of Health and Human Services (HHS).

 

Comments

[Stephen C Schimpff]

04:28 PM on 09/06/2012

Kenneth Thorpe makes some very good points in this post. Chronic illnesses account for 70-85% of all claims paid. Most chronic illnesses today are the result of lifestyle issues including a non-nutritious diet, too little exercise, chronic stress and still 20% smoking. These lead to obesity and hypertension, heart disease, cancer, diabetes, chronic lung disease and others. These diseases are difficult to manage, last a lifetime (some cancers excepted) and are expensive to treat.
The key to reducing costs is twofold.
First, good programs of prevention and wellness. Programs to detect high blood pressure, high cholesterol, obesity, and cancer are effective in either preventing disease or catching it in an early stage. Workplace wellness programs have been shown repeatedly to be effective in improving diet, fitness, reducing stress and smoking and thus leading to a healthier workforce and lower insurance costs over time. These will pay off handsomely in the long term.
Second, coordinate the care of those with chronic illnesses. They need a multi-disciplinary team approach but the team needed a quarterback – the primary care physician (PCP.) Here the key step is to reimburse the PCP sufficiently to take the time for good coordination. This will lead to many less referrals to specialists, fewer test and procedures –better care at much lower cost. This needs to change now to bring down costs dramatically.
Stephen Schimpff, MD