Yesterday The Department of Health and Human Services (HHS) announced a new initiative to accelerate the shift in how we pay for health care from one that relies primarily on pay for volume (fee-for-service--or the more you do the more you get paid) to one that emphasizes value (ideally the better outcomes you achieve, the better you do financially).

Community Catalyst embraces this effort because we see too clearly the failings of the current system. Despite the huge sums we spend on health care, quality is uneven and often varies dramatically by geography, income, and race or ethnicity. Far too often patients end up in a hospital bed, emergency room or nursing home because they didn't receive the right care at the right time in the community. In fact, the Institute of Medicine identifies failure to deliver the right care as the biggest source of unrealized value (and biggest opportunity for savings) in our health care system.

That said, this is far from a risk-free venture. As Alan Weil cogently argued in a Health Affairs blog in December payment reform carries with it many challenges, including the fact that it is far easier to measure cost than quality, that payments tied to outcomes can create an inducement for providers to avoid harder-to-treat patients and that standardized outcome measures may not promote the best care for patients who may have very different needs and goals.

We believe that Weil's critique is well-founded and we recall clearly the shortcomings of an earlier generation of payment reform initiatives (the "managed care" efforts of the 90s). While we think these risks and shortcomings can be overcome, we also believe that this will only happen with concerted effort and commitment. From our perspective, the recipe for "better, smarter, healthier" must include these five ingredients:

1) Robust consumer engagement

As we outline in our paper the Path to a People-Centered Health System consumers must be active partners in the transformation at three levels:

First--as individual patients the system must move to assess and improve what has been variously called patient activation or patient confidence—the ability of patients to understand and manage their own health care. Higher levels of patient confidence have been found to correlate with both better outcomes and lower costs and boosting the patient confidence of lower income patients could be an important tool to reduce health disparities in the U.S.

The second level of consumer engagement is at the level of health plans or integrated delivery systems. Our Meaningful Consumer Engagement Toolkit outlines the elements and steps that plans and delivery systems need to take in order to make their patients/members partners in delivery quality care.

The third level requires consumer engagement in the policy-making and monitoring process. While the voices and expertise of other stakeholders are essential, it is almost certain that reform efforts will go astray if consumer voices are absent from the table or are relegated to token status. Effective consumer voice in the transformation will require resources and building connections across all three levels of consumer engagement, so that consumer representatives at the delivery system and policy making levels are informed by the experiences of individual patients.

2) Getting the financial arrangements right

Financial incentives create a powerful gravitational pull, influencing the behavior of clinicians, health systems and plans. If payment arrangements are not carefully designed, there will be incentives to under-treat or avoid certain patients. Providers who see a disproportionate share of sicker or poorer patients could be disadvantaged--exactly the opposite of what we are trying to achieve. Although there is much reason to be encouraged by the current initiatives that HHS is promoting such as payment incentives to reduce readmissions and medical errors, there are still some bugs in these payment initiatives that need to be worked out. Expanding value-based payment is the right thing to do, but moving aggressively in this direction without taking into account the greater degree of difficulty faced by some plans and providers will compound the challenges that lower-income populations are already facing.

It is also important to make financial incentives intelligible. A blizzard of conflicting public and private sector incentives will create signals that are impossible for providers to interpret and will fail to nudge the system toward better performance. 

3) Strengthening due process rights and patient support

While financial incentives do much to set the direction of the delivery system, no set of arrangements can ever be perfect. That is why as we move further into systems where providers bear financial risk, we also need to make sure that we have robust grievance and appeals processes and complaint resolution programs such as ombudsman initiatives. New systems of integrated care and changing plan designs can also create a dizzying array of choices for patients. Patient navigators, support for health care and health insurance literacy and help with picking a Medicare Advantage plan or understanding what it means to be receiving care from an Accountable Care Organization are all crucial.

4) Developing better consumer-centric quality measures

We all want better value for our health care dollar, but how do we know when we are getting it? A lot of the current quality measurement and reporting efforts are not meaningful to patients or intelligible to them. Many measures focus on processes and too few on outcomes. Although HHS has made great strides in promoting transparency on cost and quality in recent years, we still have a long way to go. In some areas likely to be both understandable and meaningful to patients, such as diagnosis errors, there is almost no information available.

Measuring and reporting on patient confidence, preventable events such as readmissions and medical errors will take us part of the way forward but more needs to be done to make quality measurement accessible to patients--especially if we are going to rely on patient/ consumer choice as a tool to drive performance and reduce costs. At the same time, a blizzard of overlapping and conflicting quality measures is likely to prove self defeating. As we move forward to harmonize public and private sector quality measurement simplicity, intelligibility and, outcomes need to be our touchstones.

5) Improving data collection and transparency

Obviously data collection and reporting is a thread that runs through the entire effort to promote better outcomes and smarter use of health care dollars. In addition to developing measures that better reflect consumer concerns, we have to do a much better job at presenting and disseminating data in a way that is intelligible. In particular, because of the risks inherent in the effort, it will be essential to strengthen data collection and reporting that could reveal disparities in treatment and outcomes based on race, income and disability. Enrollment and treatment patterns must be scrutinized for evidence of under-treatment or avoidance. 

The good news is that many of the elements described above already exist at least in rudimentary form or in some specific location or system. Others have been explicitly flagged for action by HHS as part of the new initiative. Moving forward on these fronts will ensure that what we get from the transition to value-based-payments is not just cheaper care, but better care.

This entry was originally posted on the Sullivan Alliance's Leadership Blog. 

Change is hard. Change takes time. Change is worth fighting for especially when it relates to improving access to oral health care. Faced with an oral health crisis, a decade ago the Alaska Native Tribal Health Consortium (ANTHC) turned to a nearly century-old dental provider model to provide care to their underserved residents. Yet, rather than being championed for employing an innovative and cost-effective approach to address their dental crises, the ANTHC was sued by the American Dental Association. The ANTHC prevailed and as a result, introduced a proven, culturally-competent and patient-centered approach to delivering dental care in the United States. Today, dental therapists are helping 40,000 previously unserved people get care where they live, when they need it.

The innovative approach adopted by ANTHC has become the most disruptive policy solution offered in oral health policy in a generation. As a result of Alaska’s example, Minnesota authorized dental therapists to provide routine and preventive care to the state’s underserved residents. Now, over a dozen states and tribal organizations are pursuing policy change to authorize dental therapists.

After nearly a decade in existence in the United States, the movement to establish the practice of dental therapy is gaining significant momentum despite the strong and well-financed opposition from the American Dental Association. In 2014, we saw great progress:

• ANTHC celebrated 10 years of dental therapy and dental therapists increasing access to over 40,000 Alaska Natives
• The Minnesota Department of Health issued a report highlighting that dental therapists that have practiced in Minnesota since 2011 and have expanded access to care, reduced wait times for rural patients, and can potentially reduce hospital ER visits for dental problems. They’ve also improved how dental teams function and as result are making care better for patients.
• Maine passed legislation to establish the practice of dental therapists
• The Washington Post editorialized in support of dental therapists
• The New York Times featuring dental therapists in Social Fixes Column and then a month later noting that dental therapists are “changing the world.”
• The Albuquerque Journal endorsed using dental therapists to address New Mexico’s unmet health needs.

As we start 2015, over half a dozen states are pursuing legislation to expand access to dental care by adding dental therapists to the dental team.

In New Mexico, which nearly established dental therapists last year, we’re seeing public health leadership such as Secretary of Health and Human Services Dr. Alfred Vigil highlighting the need for better care.

The reason there is so much momentum is the growing body of evidence highlighting the efficacy of the model in providing care to vulnerable populations and the significant unmet oral health needs in the nation, for example:

• More than 181 million Americans go without regular dental visits
• More than four out of ten children go without regular dental care
• 51 percent of children on Medicaid did not receive any dental care in 2011, and
• 45 million people live in areas where they can’t get dental care – and millions more can’t afford it

Now policymakers and the media are recognizing that dental therapists are part of the solution because the evidence that mid-level dental providers increase access to care and provide care at the same level of dentists is undisputed – with more than 1,100 articles showing that dental therapists increase access to quality, safe care.

Even the ADA’s own study found that “[a] variety of studies indicate that appropriately trained midlevel providers are capable of providing high quality services.” The same report noted that dental teams with mid-level providers were more successful at providing services to populations with untreated decay than dental teams with dentists alone.

Thankfully, state legislatures across the country are poised to make mid-level providers part of the solution to our lack of affordable dental care. We expect more to be launched this year. We also expect more states to authorize mid-level dental providers because, like Maine in 2014, policymakers will recognize how essential dental health is to maintaining overall health in their communities. Change is imminent.

Learn more about the Sullivan Alliance here. 

You can almost set your clock by it: at least once a year, a major piece of investigative journalism documents the struggles of uninsured and underinsured people who carry heavy medical debt and are facing collection actions from hospitals and other providers. (See “From the ER to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages,” ProPublica and NPR, 2014; Steven Brill’s 2013 article “Bitter Pill: Why Medical Bills Are Killing Us,” Time, 2013 (subscription required); “Prognosis: Profit” series, Charlotte Observer, 2012.) Without fail, these stories cut to the quick of why access to affordable, high-quality health care is a moral issue. They also highlight the tensions that exist between profits and patient care, especially the long-lasting problems that arise for patients when hospital billing and collection practices don’t acknowledge patients’ financial realities. 

Just before the new year, the Treasury Department and IRS issued long-awaited final rules that directly address hospital financial assistance, billing and collections. The regulations finalize the details for a broader ACA mandate that governs how tax-exempt hospitals provide community benefit. Historically, hospital community benefit programs—including financial assistance or free care—have been a mixed bag in terms of content, governance, and level of investment; and states have taken an uneven approach to regulating hospital behavior. While the new regulations leave most of the details to hospitals to decide, they set a new federal floor that greatly increases transparency on financial assistance and collections, provides some protection against medical debt and overcharging, and offers communities greater insight and potential influence on the way hospitals understand and address broader health issues.

What Do the Rules Change?

Transparency. Transparency is at the heart of these new rules. Financial assistance, billing and collection policies will now be available for public review, with hospitals required to disclose detailed information about eligibility, how to apply for help, and how they use third-party data to screen patients for presumptive eligibility. Translation standards for printed and online financial aid materials improved, with hospitals required to translate policies into the primary language of populations to 5 percent or 1,000, whichever is less, of people “likely to be affected or encountered by the hospital facility.” Hospitals must publicly post their community benefit planning documents for public comment. These simple requirements have been hard to come by at the state level. Now, they’re the law of the land. 

Curbing no-holds-barred billing and collections. Unfortunately, the new rules don’t include an outright ban on some of the most aggressive collection actions in use today, nor do they require hospitals to observe a minimum threshold for eligibility for financial assistance—two things advocates were hoping to see. But, they do provide patients with more procedural protections against collection activity than they’ve had in the past. In addition to notifying patients and the public that financial assistance is available, hospitals have to assist patients with the application process (hospitals can perform this function themselves or outsource it to a non-profit organization or government agency). Patients have a minimum of 120 days from the first post-discharge bill without having to worry about “extraordinary collection actions,” and hospitals that begin these collection activities must suspend them if they receive an application for financial help up to 240 days after the post-discharge bill. Critically, if a patient is deemed eligible for financial help under the hospital’s policy, they can no longer be charged sticker price—“gross charges’—for care. Instead, they can only be charged the “amount generally billed” to an insured patient receiving the same services. (They’ve got to disclose their methods for determining this amount in their financial assistance policy.) This introduces some parity into a billing system that often perversely penalizes those who can least afford to pay hospitals’ high mark-ups.

Community input and better health planning. The ACA requires tax-exempt hospitals to use a health planning tool, the community health needs assessment (CHNA), to better understand community health needs. It also requires hospitals to develop an “implementation strategy” for meeting those needs. One implication is the potential to streamline community benefit investments toward priority issues within a community, avoiding an ad hoc approach that dilutes precious resources. The process encourages collaboration among hospitals, public health and community advocates, providing opportunities to take a deeper dive on systemic issues (like financial barriers, environmental problems, housing, nutrition) that impact health but defy easy solutions. The final rules mostly mirror earlier proposed rules here, though hospitals now have to include evaluation data for previous efforts in their CHNAs. Hospitals must solicit community input and consider the input they receive, though they are not required to make drafts of the CHNA or implementation strategy available for public comment. (NOTE: Most hospitals, relying on the proposed rules, have already completed one CHNA, which should be available on their websites and/or on request. Hospitals do need to consider written comments they receive in the next round of their community benefit planning.)

The buck stops here. Despite pushback from some quarters, the IRS held firm that tax-exempt hospitals can’t absolve themselves of responsibility by outsourcing their billing and collection responsibilities to third parties or selling patient debt. Furthermore, hospital boards bear ultimate responsibility for compliance with these new standards. This should raise the internal profile of community benefit, financial assistance and billing—a critical move, since so many details are left to hospitals to decide.

What Does This Mean for Our Work?

There is no question that the final rules are a step in the right direction. They provide an important tool—in some places, like many states that have not closed the coverage gap, the only tool—for addressing health and improving access to care for low- and moderate-income people and others facing high-cost care. And, they offer hospitals clarity and consistency on the federal level (states can go further than the federal rules and some have). As our health care system moves toward integrated care and capitated payment, the CHNA requirements provide a great opportunity for communities and hospitals to work together to achieve better outcomes. On the financial front, hospitals can still choose to be miserly, but the new public reporting may dampen enthusiasm for the “old ways” of collecting. 

Effectiveness will ultimately depend on hospitals making a good faith effort to comply with the spirit of the law, not just the letter. And that means advocates and community organizations must remain engaged with local hospitals, monitoring their compliance and taking advantage of opportunities to shape policy to meet local needs.

Patient-friendly billing practices don’t just help patients. Hospitals can benefit, too, from adopting better methods to collect. 

I recently participated in a panel discussion on medication safety issues with a colleague who serves as a patient advocate. We've been on panels together and make a great team—a doctor and a lawyer who are actually on the same side! This time, though, she said something that I hadn't heard her say before and that I had some trouble with. She criticized a pharmacist who suggested to a patient that a therapeutically equivalent drug could be substituted for the medication her insurance company no longer had on its formulary. She emphasized to our audience that what the pharmacist was suggesting was not the same chemical compound as the drug she had been taking. She thought this was wrong.

My colleague is a staunch consumer advocate who has courageously fought for health justice. We have been allies in numerous campaigns on behalf of the public's health against entrenched vested interests. I have nothing but the highest regard and admiration for her. Yet her criticism of the pharmacist who, following an insurer’s pharmacy benefits management plan, suggested a clinically reasonable therapeutic substitution is emblematic of a dilemma facing patient advocates. The horns of this dilemma pit the rights of individual patients to the health care they want versus the greater good of the community.

The enormous resources poured into health care in this country—about $3 trillion dollars a year—make this conflict unavoidable. The struggle to achieve universal, affordable, high-quality health care is far from over despite the enactment of the Affordable Care Act. Tens of millions of Americans remain uninsured. Those with insurance face higher and higher out-of-pocket spending through the imposition of high deductibles. Premiums continue to rise faster than wages, especially for lower wage-earning families.

High costs for health care also impede our ability to fund key social services such as food security, adequate housing, affordable daycare, safe neighborhoods and recreation that are vital to good health. It also undermines our ability address vital global challenges as well, such as global warming and the alleviation of suffering in the developing world that can lead to international terrorism.  

If we don't rein in health care spending, it is almost certain that our efforts to advance a competing, life-saving agenda will be significantly undermined. 

Bringing this lofty conversation down to more pragmatic issues, let me return to the topic of therapeutic substitution. During the summer months, my eyes itch from pollen allergy. I buy a 10-ml bottle of ketotifen eye drops over the counter for about $12. I could also get the same relief with a prescription for Patanol (olopatadine) that costs $169 for a 5-ml bottle. I've used both and find they work equally well. What's wrong with at least starting out with the less expensive alternative rather than the one that costs more than 28 times as much?

While it is illegal for a pharmacist to substitute one drug for a chemically different drug that does the same thing, public and private insurance plans achieve the same result by changing their formulary. For instance, I'm frequently confronted by a change in what Medicaid will cover for stomach-acid problems—one year it's Nexium and the next year it's Protonix, whichever the state is able to get a better deal on. In almost all cases, the drugs work equally well even though they are different chemical compounds. Rarely, a patient will find that one works better than the other, and I can obtain an exception from Medicaid to allow the patient to continue on the drug that is no longer on the preferred drug list.

Commercial health insurers are doing the same thing by using different copayments for drugs on different tiers Going back to Patanol eye-drops, for instance, my insurance company lists that drug as a tier-3 drug that requires a $45 copayment. The problem is that not all patients know that a lower-cost alternative is available. There is no generic Patanol that the pharmacist can substitute, but there is a therapeutic equivalent, ketotifen, that will probably do just as well.  Using Patanol costs the patient more ($45 versus $12) and the health plan more ($154 versus 0), which can eventually increase premium costs too.

Patient advocates are justifiably wary about policies and practices that limit patients' ability to get the health care they want. Our sad national legacy is one that all too often denied patients, especially poor patients, the care they needed. Patient advocates should continue to be champions for low-income and chronically ill people and to fight for the right to health care that is needed. But they should also recognize the need to limit wasteful health care spending, because these at-risk  patients are also the first to suffer when high costs lead to cuts in programs and benefits. Policies like therapeutic substitution, campaigns like Choosing Wisely , and initiatives like Community Catalyst’s Voices for Better Health can stem unnecessary spending while safeguarding and improving the health of the patient.

The role of patient advocates should not be one of fighting any perceived infringement of patients to any health care service or product available, but rather one of partnering with patients to secure safe, cost-effective and better organized health care. In the long run, there really is no dilemma—this is the best strategy for individual patients as well as the broader community.

Stephen R. Smith, M.D., M.P.H., Community Catalyst Physician Consultant

So long, farewell. But first, a few of my favorite things.

As I wrap up eight years at Community Catalyst, I’ve been reflecting on the momentous changes in the health care system I’ve been lucky to be part of through this work. Before I say farewell, I wanted to mention a few of my favorite things - as well as a few hopes for the future as I say goodbye to health advocacy work… for now.

1. The Affordable Care Act. I joined Community Catalyst after working on Massachusetts health reform, and for a number of years it seemed the only path to expanding coverage was a state-by-state reform model. Then the 2008 election created the momentum for national reform. The work of state advocates in that fight – organizing rallies, writing op-eds, educating policymakers – led us to a place unimaginable a few years ago. Now 9.5 million uninsured people have coverage. Millions of people do not have to worry that a pre-existing condition will keep them from treatment. Even with all the law’s implementation challenges, sometimes I have to pinch myself when I think how far we have come in such a short time.
    
2. In-person assistance.  Over the past few years, I am fortunate to have witnessed first-hand the enormous growth in training thousands of experts to assist consumers in understanding our extremely complex health system. This issue has long been a priority of Community Catalyst, and to work with a new crop of CAPs, Navigators, CACs has been gratifying. We went from having a few wonks who understood the system to building community-based capacity in every state and city to help people navigate the health system.
    
3. Growth of consumer health advocacy. When I started at Community Catalyst in 2007, most consumer advocacy organizations operated on a shoestring with a limited policy agenda. Today, Community Catalyst works with a wide range of groups on multiple fronts – to improve dental access, health equity and care for dual eligibles. Our health system and the care available to consumers are better for it.

But there is more work to be done. Here are a few areas where I hope to see further progress:

1. Discrimination.  The ACA took made huge strides in making sure people have health coverage. The next step is to dig in and use these new tools so groups that have been systematically discriminated against can get the care they need. There are exciting developments in some areas, but there’s more work to be done to ensure all people of color, people with chronic illnesses, transgender people and those who do not speak English as a first language get high quality care.
    
2. Make assistance permanent. While we have made great progress in creating a workforce of experts to enroll people, we know from Massachusetts health reform that the need for assistance with navigating the health system does not go away after the first few years of reform. The issue is now at a tipping point - there is an opportunity to use the expertise that has been created to build an on-going system of assistance that keeps people covered and troubleshoots problems.
    
3. Retain the coverage gains made. As with any significant change, health care reform still has fierce critics. The immense gains in health care access will continue to face challenges. But as we continue to build the capacity of health advocates on the ground, we will continue to move closer to fulfilling the promise of health care for all. 

This is my last blog before I move on to the Massachusetts legislature. But I plan to keep an eye on your work, and I look forward to more good things to come. I am so proud to have worked alongside those who are fighting for health care justice and hope our paths cross again soon.