October 11, 2015

Response to Congressman’s Murphy Comment: My Views on the Health Insurance Reform Legislation

The narrow purpose of this blog is to respond to Congressman Murphy’s comments, but the broader purpose is to give my perspective on the recently enacted health insurance reform legislation, so this blog will be very long.

Preliminary Comments

There were many good things in the legislation, including an enhanced focus on prevention, on health care quality, on expanding the reach and supply of community health centers, on tackling the challenges of long-term care, on correcting issues associated with senior citizen prescription drug coverage, and on experimenting with innovative and potentially transformational payment methods. There was much to like about it, and I will devote my life to working with what has been enacted to make it achieve the goals of transformational and improved health care.

I empathize with lawmakers like Congressman Murphy who do not get presented with perfect, simple choices, especially on an issue like this, which is so contentious. They have to make choices based on imperfect options. He, like many of his colleagues, is trying to do the right thing, and has an exceptionally difficult job, and does it extremely well.

I took a few extra days to read this legislation, which was not easy to do, and his comments made me think much more carefully about my views, so I thank him on behalf of all of us.

Why I Consider the Legislation Flawed

Ultimately, this legislation was flawed for two big reasons:

  1. It set the wrong priorities; and
  2. On the right priorities, of which there were many, its strategy was to defer implementation, which leaves far too much risk that these priorities will either never get accomplished or will get delayed.

The legislation aspired to do many things:

  • Promote prevention and wellness;
  • Improve health care quality;
  • Improve health care access;
  • Control health care costs;
  • Move toward universal, affordable health insurance access;
  • Establish uniform federal standards for minimum health insurance benefits; and
  • Create competitive insurance exchanges.

There were other goals, but these are the ones on which I want to focus.

Based on the level of specificity in the legislation, the effective dates in which various provisions took effect, the level of funding provided, and the enforcement mechanisms put into place, as well as the communications messages delivered by the President and the Congress, by far, the highest priority in this legislation was to address health insurance market reform. Universal, affordable health insurance was the primary goal and was given the highest priority. By expanding coverage and the health care provider population, this legislation will make any transformational restructuring it ultimately triggers far more difficult to achieve. It will enlarge the size of the vested interests who will fight the transformational efforts the rest of the legislation contemplates.

Why Making Health Insurance Access the Prime Goal Creates a High Societal Risk

Although one could argue that providing universal health insurance will give citizens the financial resources to get less expensive, earlier, more efficient health care, the combination of increased health insurance money, higher payments to primary care physicians and to physicians committing to practice in underserved areas, more covered citizens, and more health care providers makes it highly likely that demand and cost will increase. Unless the costs of this legislation are offset, even conservative estimates would suggest that it will cost our society more.

Therefore, we have to find ways to keep the cost of health care from overwhelming and crowding many other vital societal needs. We already spend over $2.5 trillion, or 16.5% of our GDP, on health care, far more than any other developed country, and get poorer quality health outcomes than any other developed country.

This legislation has prevention and wellness coverage requirements, improved access for prevention and early interventions, and grants to communities from improved wellness. Beyond the legislation, there are many good initiatives, some which came into existence as a result of the stimulus legislation a year ago.

Unfortunately, we needed a much more decisive statement of national purpose by the President. As a society, we need the equivalent of a “health dividend,” very much like the decision by Presidents Bush and Clinton in the early 1990’s to redeploy hundreds of billions of dollars of monies spent on defense during the Cold War to other societal needs.

We can and must take about $1 trillion from what we are misspending on health care, improve health care access and quality, and insure that everyone still has access to universal, affordable health insurance. Based on my Pitney Bowes experience, this can be done, but it is politically and conceptually difficult to accomplish.

To do this, we have to aggressively attack the sources of demand for health care, only some of which relate to improved health outcomes.

What makes demand reduction so difficult to accomplish is that more care is not always better care. In fact, as experts like Dr. Dennis Gottfried, in his great book Too Much Medicine and Shannon Brownlee, in her great book Overtreatment point out, we get too much of the wrong kind of care.

Why this Legislation is Unlikely to Reduce the Demand for Unnecessary and Even Harmful Care

The first problem with the legislation is that all the messages relating to it imply that there is an optimal level of care which health insurance access will help underserved people get. As I have pointed out in many blogs, both my Pitney Bowes experience and the research done by many other people demonstrates that poor access to primary care physicians, not to health insurance, is the primary driver of inadequate or inefficient health care.

Unless something dramatic happens, this problem will get worse because only 3% of our medical school graduates are going into primary care. One of the root causes of our excessive demand and cost is that we have a far higher mix of specialists compared to primary care physicians than any other developed country.

Increasing payments to primary care physicians or forgiving student loans will help reduce the shortages, but they are not sufficient. Physicians will continue to become specialists because specialists make three times as much money as primary care physicians. They will serve in wealthier areas because the quality of life is better, the patients are easier to serve, and the cost of doing business is probably lower since patients are more likely to show up for appointments.

The only way in which this imbalance between specialists and primary care physicians gets addressed is to radically change the relative payouts for health care between them. This is almost impossible to imagine. The reimbursement system for physicians is based on a methodology developed at Harvard University called The Resource-Based Relative Value System (RBRVS), which heavily rewards complexity and skill and inadequately rewards low-cost, low-tech, but successful, interventions.

Lawmakers and the Secretary of Health and Human Resources have two choices:

  • They can keep specialist payments at the same level, but bring primary care payments up to parity. That would be astronomically expensive, or
  • They can increase primary care payments and simultaneously reduce specialist payments. Specialists are extremely powerful and well organized politically. I cannot imagine lawmakers taking on the challenge of reducing specialist income.

Why the Many Other Provisions in this Legislation Designed to Improve Quality, Reduce Excessive Treatment, and Restructure Health Care are Unlikely to be Effective

The financial viability of this legislation heavily depends on successfully executing on the many transformational payment and delivery initiatives it contains, some of which Congressman Murphy mentions in his comments. He correctly points out that, if implemented, these will be very positive.

However, my experience with lawmakers at all levels is that this radical, system-level restructuring will be almost impossible to carry out unless there is a very different set of political priorities and a much more customized approach to the problem.

Think about these scenarios:

  • Scenario 1: An Expert Panel Creates a Payment System That, Based on Quality Measures, Puts a Number of Poorly Performing Hospitals at Risk of Closure. On December 9, 2008, the New York Times examined “how hard it can be … to close or shrink hospitals, even when there is evidence they are providing costly and below-average care.” The Times reported “hospitals are rarely closed or hit with significant financial penalties for hurting patients. In addition, local hospitals typically are large employers and communities rally behind them when they face the threat of cuts.”

The Times profiled State University of New York’s University Hospital, which is ranked by HealthGrades among the least safe hospitals in the country. The hospital-ranking Web site also says, among other deficiencies, University Hospital has a higher percentage of certain hospital-acquired infections and patients face a greater chance of dying of pneumonia compared with other state hospitals. The hospital also has faced a number of malpractice lawsuits. A state panel in 2006 had recommended University Hospital, along with 50 other hospitals, be downsized or merged because of problems and said that nine state hospitals should be shut down. However, lobbying efforts by affected hospitals and universities prompted a reversal of the recommendation.

If we cannot close badly performing hospitals today, how is any system that depends on addressing health care quality issues on a broad scale ever going to work?

  • Scenario 2: An Expert Panel Concludes That Many Expensive Cancer Treatments are Ineffective and May Even be Dangerous and Should not be Covered. The financial viability of this legislation also depends on being able to deny coverage for extremely expensive, but questionable, cancer treatments. Desperate patients and advocacy groups making saying no in these situations virtually impossible.

Our lawmakers have difficulty closing military bases, post offices, and other marginal public facilities, especially when they provide vital employment in economically distressed communities. Despite the heroic efforts in this legislation to frame a transformational health care system, it is far too tempting for lawmakers to jump ahead and get everyone insured, pump up spending for health care, and delay or never undertake the extremely unpleasant task of creating winners and losers that results from restructuring the system.

Final Comment

I made the observation I did about the legislation being flawed because I believe it evidences a political bias toward spending more taxpayers’ money on a flawed system, and it does not evidence a sufficient political will to execute on the several hundred pages of innovative health care system restructuring contained in the legislation.

My experience with a wide range of political issues is that, when millions of jobs are affected, and there would be a major disruption needed to make market transformation happen, the parts of this legislation that pay more for certain activities have a far better chance of happening than the parts that would result in reduced payments.

I hope I am wrong, and I will work hard to realize the potential contained in this legislation. However, I hard it hard to conceive how even a leader with tremendous political capital will make some of the decisions we now have to make if this legislation is not going to create a long-term financial crunch.