Dear Ed: Clear, thoughtful and articulate. Thank you for taking the time to cover so much ground. It is beyond me why no Democratic candidate in the debates except Marianne Williams has mentioned that we should focus on what we are paying for, and shift from illness to well-being. Instead, all the debate energy goes to buying more of the same broken system, and we continue to diverge into two countries on health: by income and by geography. Finance drives the whole US system. We monetize illness. Investors make money in health by getting the system to spend more. Unlike every other industry, IT is driving health costs up. My concern about your comments is you are circling but not addressing the central point. Until we change the metrics for which payment is made, we will get versions of the same outcome. Movement toward value based payment is very, very different than defining vitality (the best a person can be) or thriving and paying for progress towards and achieving that for a population group. Rewarding new outcome metrics beats hell out of recreating fee for service on the social determinant side (one by one as "ROI is proven"). This is really just medicalizing some portion of SDoH interventions. We will pay for transport to the doctor, but not to the food store or job. We will pay for housing for the homeless ER frequent flier, but not relieve the disease causing stress on a family of paying more than half their income for rent. So new metrics. But how to we change finance? Most everyone I know believes that greater investment in primary care and integrated SDoH will produce significant ROI. They just can't say overall how much and when. And even if they could, there is no way to capture those benefits and "return" them upstream. So we also need a new mechanism to solve the wrong pocket and ROI timing issues. Wrong pocket applies upstream and downstream. As you say, the income streams to fund primary care and social determinant interventions need to be braided, but they come from multiple layers of government, and are not just health care players. So giving all the health money to Governors won't solve the problem. In a mirror image, the benefits and savings occur with different entities at different times, also are not just health care, and also need to be "braided" (or aggregated) to get back to the first group, the intervenors. Why do we expect players at either end of the stream to figure this out when the gap between action and return may be 5, 10, 15 years or more? Medicaid and Medicare reimburse medical expenses, and they can pay for medical savings when those occur -- but why would we expect them to make a bet on combinations of primary care and SDoH producing ROI in time frames beyond a fiscal year or more? THAT is a role for a new form of social impact investment, bridging these two worlds. We don't have enough data yet to do that, but with new holistic well-being metrics and field experience with comprehensive integrated approaches to achieving them, we should develop the neccessary data rapidly. Then we could offer investors profit opportunities improving the lives of poor people and reducing overall health spending (and spending on other social failures, e.g. corrections). That would be fun. To be continued. Thanks again for your thought provoking piece.
Submitted by
David Aylward
on Tuesday, November 12th, 2019 at 18:33 pm
In a recent blog, I argued that the 2020 election debate should address broader health issues: reinforcing our public health system, addressing policy in multiple sectors through a health lens, and moving the health system “upstream” to address social needs of patients and social determinants at the community level.
That doesn’t mean public health advocates can sit out the debate on health insurance. Proposals cover a full spectrum: Medicare-For-All, returning control to states through block grants, and points in between that would build on the Affordable Care Act. If either party were to emerge with a mandate, it could lead to substantial change in health spending and potential restructuring of the health care system. Love them or hate them, any such reform would provide an opening to advance population and public health goals.
Yet even bold proposals are largely silent on questions beyond insurance coverage for individuals. For example, if there will be more money, new decision-making mechanisms, or more flexibility for decision-making, to what end will they be used?
Achieving Long-Standing Public Health Goals
What would public health advocates hope to accomplish as the health system changes?
For starters, there is widespread agreement that health spending is not optimally balanced. The system is designed to focus on “downstream” treatment of the sick, rather than “upstream” investment in prevention, community health, or population health. Movement toward value-based systems that focus on outcomes rather than volume are gaining momentum, but without a more fundamental reconsideration of the health system itself only incremental progress is likely.
Second, the US is way out of line with countries with better health outcomes when looking at the proportion of spending devoted to medical vs. social services. Given the influence of social and economic factors on health, breaking down the walls between medical and social spending is a good start. This includes broadening the defining health-related spending; investing more in health-related social needs of patients that inhibit positive outcomes; building infrastructure and partnerships that facilitate handoffs of patients; and investing savings from health system reforms in “upstream” efforts to address more basic social determinants of health.
Third, interventions at the community level lack dedicated funding streams that are comparable to those for clinical interventions for individuals. Currently, most new clinical treatments and drugs rapidly become covered benefits, and public policy mandates that clinical preventive services are covered benefits for individuals. The HHS Secretary is even empowered to add Medicare benefits for cost-saving treatments. Yet there is no parallel concept of mandatory spending for public health or health-related social services that demonstrate improved health outcomes or economic benefits.
Finally, our focus on individual coverage reflects a value on economic security for individuals -- potentially saving some of the 500,000 families that fall into bankruptcy from medical spending -- but ignores the economic impact of health on communities. Investments in public and population health can help address the tsunami of chronic diseases and social and economic deficits that can bankrupt public treasuries, sap economic vitality as they diminish our length and quality of life.
Rationalizing Decision-Making and Resource Allocation
The approaches of the two parties diverge widely in their philosophy, goals, and spending. Yet proposals in both parties shift decision-making and funding streams in ways that create new opportunities. Such reforms suggest ways to solve the “wrong pocket” problem, where the financing for public health and prevention often come from one pocket, while the savings goes into another.
Democratic candidates focus on moving toward universal coverage, with expanded Federal financing or mandates through the ACA, Medicare, or other mechanisms. Any of these approaches would consolidate more financing and decision-making at the Federal government – even as far as placing all funding and control in the hands of a single Federal payer.
Republicans, meanwhile, have different objectives, including control of Federal spending and mandates, returning flexibility to states and individuals, and lower cost for privately insured. The Republican Study Committee recently revived proposals for block grants to replace the ACA’s Medicaid expansion, providing governors with wide latitude to transform the way these dollars (and others already at their disposal) are spent, in ways that could extend considerably beyond the kinds of systems change already possible with federal waivers.
Even if the 2020 election doesn’t bring a mandate for nation-wide reform, existing efforts (including many at the state level) could benefit from exploring ways to use new decision-making structures. All payer systems, such as that evolving in Maryland, can be more strategic in guiding health spending as they expand the range of covered providers and rethink the most productive investment of health dollars. And in moving beyond existing waivers toward the largely unexplored potential of 1332 waivers, governors may be in a position to test initiatives to better integrate health and social service programs.
Needed: Mechanisms, Guardrails, and Evidence
For reforms to serve public health goals, we need to grapple with fundamental governance issues. If decision-making and financing are shifted or consolidated, we need candidates to explore:
- Can new decision-making structures and rules facilitate investment decisions that move the overall system toward primary prevention and greater value in the delivery system?
- Can we redefine health spending to bridges the boundaries of medical and health-related social services spending?
- What kind of mechanisms can be established to facilitate data sharing and service integration across health and social services systems?
- How will decisions be made, and how will consumers and communities be included?
- What kind of guardrails will safeguard individuals and institutions, and how will those impacted be protected during transitions?
- If governors were given new flexibility for health spending, what other reforms could they be pursue to better integrate funding streams addressing nutrition, housing, and other health-related social supports?
If decision-making mechanisms and rules can be established that allow greater movement toward achieving value and public health goals, more evidence will be needed to inform decisions, including:
- Assessing return on investment for patient-specific and community level initiatives;
- Understanding links between social interventions and eventual health states and outcomes;
- Estimating attributable “shares” of positive health outcomes or savings for use in allocating investments among those who share risk and rewards; and
- Providing evidence for revisiting definitions of “quality improvements” that would allow investment in more upstream interventions as health benefits under the medical loss ratio.
Why Should Public Health Advocates Engage?
There are clear differences between parties and candidates, and voters will likely focus on practical and ideological choices around coverage for individuals rather than the extent to which any plan achieves broader public health goals. But if we fail to elevate the opportunities to address such goals as reforms are considered, we risk missing out on a generation’s worth of financial and political capital. Allowing success to be declared on health reform without actually addressing underlying drivers of health and vitality would be a loss for public health.