One Sentence Health Care Reforms: 200 Alternatives and Steps Beyond the Affordable Care Act

One-Sentence Health Care Reforms:

200 Alternatives and Steps Beyond the Affordable Care Act

Curtis P. McLaughlin

Smashwords Edition

License Notes

Thank you for downloading this ebook. This book remains the copyrighted property of the author, and may not be redistributed to others for commercial or non-commercial purposes. If you enjoyed this book, please encourage your friends to download their own copy from their favorite authorized retailer. Thank you for your support.

Copyright 2014 by Curtis P. McLaughlin, 750 Weaver Dairy Rd., Chapel Hill, NC 27514

unikorn1123@gmail.com

Published by Herne Publishing, 1300 Ordway St., Santa Cruz, CA 97402-3515

ISBN-10: 1940462010

ISBN-13: 978-1-940462-01-1

TABLE OF CONTENTS

LIST OF ABBREVIATIONS

INTRODUCTION

Background

Why Not a Comprehensive Solution? The Lack of a Win-Win Solution

The Lack of a Win-Win Solution

The Many Faces of Quality

Moving On with One-Sentence Options

Parallels with the Institute of Medicine's Best Care at Lower Cost Report

The Essentials Identified by FRESH-Thinking

What about the Affordable Care Act?

THE ONE-SENTENCE ALTERNATIVES

Quality

Access

Universal Access Reforms A1a-A2

Incremental Access Reforms A3a-A16

Technical Management Reforms B1-B9

Management of Interpersonal Relationships Reforms C1-C4

Continuity of Care Reforms D1-D4

Measurement and Reporting Reforms E1-E12

Motivation Reforms F1-F6

System Inputs

Resource Availability

Personnel Reforms G1-G6b

Medical Technology Reforms H1-H4

Money/Insurance Reforms J1a-J16

Information Technology Reforms K1a-K9

Payment

Fee for Service Reforms L1-L7

Capitation/Vouchers Reforms M1a-M3

Bundling Reforms N1a-N3

Budgeting/Salaries

Consumer-Oriented Health Care Reforms P1-P9

Pay for Performance Reforms Q1-Q12

Competition

Antitrust Reforms R1-R8

Labor Substitution Reforms S1-S5

Strengthening Buyer Power Reforms T1-T10

Cost

Cost-Reduction Measures Reforms U1-U16

Malpractice Reforms V1-V4

Fraud and Abuse Reforms W1-W4

Organizational Learning Reforms X1-X4

Reforms Not Included

CONCLUDING OBSERVATIONS

REFORM TITLES BY TOPIC

REFERENCES

ABOUT THE AUTHOR

ACKNOWLEDGEMENTS

APPENDIX - CLASSROOM USE

POST-SCRIPT

LIST OF ABBREVIATIONS

AAFP American Academy of Family Physicians

ACA Affordable Care Act

ACO Accountable care organization

ADA Americans with Disabilities Act

AHRQ Agency for Healthcare Research and Quality

ARRA American Recovery and Reinvestment Act

AWP Any willing provider

CAHPS Consumer Assessment of Healthcare Providers and Systems

CDC Centers for Disease Control and Prevention

CHIP Children's Health Insurance Program

CLASS Community Living Assistance Services and Supports

CMS Centers for Medicare and Medicaid Services

DHHS Department of Health and Human Services

DRG Diagnosis-related group

EHR Electronic health record

ERISA Employee Retirement Income Security Act

FDA Food and Drug Administration

FFS Fee for service

FPL Federal poverty level

FTC Federal Trade Commission

GME Graduate medical education

HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems

HEDIS Healthcare Effectiveness Data and Information Set

HIPC Health insurance purchasing cooperative

HITECH Health Information Technology for Economic and Clinical Health

HMO Health maintenance organization

HRRP Hospital Readmissions Reduction Program

IOM Institute of Medicine

IRS Internal Revenue Service

IT Information technology

JAMA Journal of the American Medical Association

LTC Long-term care

MA-DP Medicare Advantage Drug Plan

MCO Managed care organization

MedPAC Medicare Payment Advisory Commission

NCQA National Committee for Quality Assurance

N Eng J Med New England Journal of Medicine

NIH National Institutes of Health

NIMH National Institute of Mental Health

OMB Office of Management and Budget

P4P Pay for performance

PHSA Public Health Service Act

QIO Quality Improvement Organization

SSA Social Security Act

INTRODUCTION

You can always count on Americans to do the right thing—after they've tried everything else.

Winston Churchill

More than 200 one-sentence reforms are outlined in the following pages. Some are alternatives to reforms in the Patient Protection and Affordable Care Act (ACA). Some display a more conservative agenda than that seen in the ACA. Regardless of how much of the act is finally implemented, there is room for the creative policy analyst to assemble over 100 unduplicated reforms. There is much to do while we work our way out from under the burden of our current health care system. The ACA is the law of the land, but continued implementation can be stymied by the House and the courts in a number of ways. Some costly provisions are likely to be bargained away in budget negotiations, and specific states may refuse to implement other components of the reform. More important, however, the bill, as implemented so far, deals primarily with access, and many entitlement and cost issues remain to be addressed. Emanuel (2014) asserts that the bill includes major cost control provisions, but admits to uncertainties about future implementation.

You will want to develop your own approach to health care reform based on your values and your objectives. What you choose will depend on what it is you want to optimize. Some will want to save Medicare. Others will want to expand coverage to everyone. Some, including myself, are more concerned about the overall quality and cost of care and not with who gets what portion of the pie or which institutions survive. No one can put together a coherent program without first defining its objectives. But any viable program will take at least 100 future reforms.

If you are considering this book as a text or supplemental course reading, please go at some point to the Appendix - Classroom Use.

BACKGROUND

In 2009 and 2010 the United States slogged through a national debate and intense legislative battles to reform its health care system. The result was passage of the Patient Protection and Affordable Care Act of 2010 with its many provisions, regulatory changes, committees, rewards, and penalties. While the ACA is far more comprehensive than anything passed in recent years, it still constitutes a piecemeal approach to reform. It deals primarily with access to health insurance and is weak on cost reduction. Some key components of the proposed legislation were dropped. Implementation was spread out over a number of years, and many implementation details were left to be defined. Unfortunately, efforts to put the law into effect have been plagued by wishful thinking and poor project management.

Most aspects of the health care system are interdependent. One can argue that a comprehensive approach to implementing the law is the rational way to proceed. However, there is considerable doubt as to whether some key elements of the ACA will ever be implemented. It could take years until we know what has been achieved beyond increased access. In any case, the law will not be sufficient to assure quality or control costs.

During the summer and fall of 2009, I assembled a series of blog posts at http://1sentencehealthcarereform.blogspot.com but stopped once passage of the ACA was assured. At the time I wrote:

Health care is a very complex process. So is reforming it. . . . Congress and the White House get bogged down in its complexity and in the logrolling that surrounds its many facets or passes a bill that is mostly window dressing. Is there an alternative for President Obama should Congress fail to perform?

Yes, there is!

Use the full extent of administrative law and submit one-sentence laws to Congress that modify the health care equation one step at a time. Will that create imbalances and inequities? Of course, at least until other one-sentence laws are enacted to deal with those added (not necessarily unintended) consequences. In the meantime, politicians may be scared into more comprehensive actions as they see their power to trade off favors to special interests erode (especially if the President vetoes any bills with extraneous stuff attached).

During the ACA debate, the focus was on a federal solution. The states, in the interim, have shown that they can and will act. (I must admit my bias as a total Federalist.) Yet the current political environment resists expansion of the role of the federal government, while the ability of the states to pass reforms, experiment, and take administrative action is evident.

The Medicaid Redesign Team in New York State has also come up with a long list of reforms, but many deal with budget matters or with interfaces with the state and county social service systems that, though important, are beyond the scope of this document. I have reviewed the team's recommendations and have included a number of them here. Massachusetts has certainly led the way with its mandates and exchanges. Oregon is making similar changes. Vermont is moving toward a single-payer system. These states are useful as learning labs and provide a number of natural experiments to study. However, their revenue resources, especially their local reliance on real estate taxes, point toward dependence on continued federal initiatives.

Why Not a Comprehensive Solution?

One problem with a comprehensive solution is that it is easier to enlist multiple constituencies against it than to align the coalition of constituencies necessary to effect real change. Aligning sufficient players often requires large side payments to interest groups. Compromises leave people who favor change less than totally committed, while those opposed to specific provisions stand adamant. Starr (2011) notes that as the negotiations went on for both the Clinton and the Obama proposals the comprehensiveness faded away. He suggests that not attacking the cost problem head on was a side payment in the ACA negotiations.

Starr also identifies complexity as a component of the current policy trap. Complexity carries implementation risks as well. Naylor and Naylor (2012) offer the following Jeffersonian observation:

Simplicity in legislation and regulation trumps complexity. The more changes that are made concurrently, the greater the risk of unintended consequences. In clinical practice, changing too many things at once leads to unintended consequences as well as confusion about causes and effects. This insight is also applicable in public policy.

. . . In contrast, the ACA alone totals 906 pages. The act contains many positive provisions. . . . However, its reach and complexity are overwhelming. In brief, the ACA may at once be too big to fail and too big to succeed. (p. 919)

The United States has never had a social contract involving a right to health care. We have stumbled into our current hodgepodge of health care financing with successive fixes starting with employment-based health insurance in the 1930s, followed by a major expansion of employment-based health insurance during World War II. Then we took on the elderly and the poor with Medicare and Medicaid in the 1960s. Medicaid started out as a safety net for the poor, but it has evolved into an entitlement program for long-term care (Grogan 2006). This transition has been paralleled by enrollment growth in other government entitlement programs involving health care, including those associated with government employment, veterans' benefits, expanded disability rolls, and an increasing prison population. The result has been government financing of roughly half of the country's health care costs. Without any sense of agreement on the limits of our shared health care responsibilities, that debate has become a subtext of the broader policy debate and stalemate over the role of government. As Starr (2011) has pointed out:

When Congress passed Medicare and Medicaid in 1965, the legislation seemed to lay to rest philosophical opposition to government responsibility for health-care costs. But what was settled in those years became unsettled again. Americans are still at odds over the most basic question about health care: whether it is a requirement for a free life that the community has an obligation to provide or a good that needs to be earned. (p. 24)

This document is not aimed at resolving that dichotomy, which exists to some extent in my own psyche. However, I generally come down on the side of universal coverage.

The Lack of a Win-Win Solution

Manufacturing waste is visible and the losses pile up around the plant. In services the bulk of the losses are invisible labor hours. In health care, for example, providers have routinely billed for repairing their own mistakes. Price competition remains weak. When workers are idled by poor scheduling or lack of demand, prices are raised to cover the waste. Most attempts to lower costs are strongly resisted by the losers through lobbying or tacit professional collusion. The bigger the proposed change, the more actors mobilize to oppose it or blunt its effect. It hasn't seemed possible to develop a win-win solution.

One potential advantage of the one-sentence approach is that it can tolerate more risks in the face of uncertainty, allowing modifications based on experience. That approach sounds wasteful, but the risks are huge when a mistake is made in a component of an integrated solution.

Many would argue that it is much easier to enact a change or program than it is to kill it. That is probably true. However, their recommendation is to wait until we have the right answer in hand, if ever (a Libertarian view). If we have the political will to enact a series of small reforms and to accept failure as well as success, then we can charge ahead. Admittedly, those are big ifs.

The Many Faces of Quality

Some argue that the United States has the world's best health care system, while others report that it ranks between the thirtieth and fortieth among the world's countries. Access for the elderly and those in extreme poverty isn't too bad, but the same cannot be said for the working poor. We have high levels of technology available but often use it inappropriately. We can point to outlier places with high costs, such as McAllen, Texas, and South Florida, and areas with good access and lower costs, such as Utah and parts of Colorado. In truth, there is no aggregate measure of cost or quality to cover the variety of conditions that exist in this large diverse country. How people judge the quality of the system depends largely on their idea of an appropriate social contract. If one believes that only markets can legitimately distribute wealth, then our quality of care, while overpriced, is pretty good when delivered. Otherwise, it leaves a lot to be desired. Medical error rates can certainly be reduced (Classen et al. 2011, Makary 2012) and ineffective treatments quarantined, and we can easily do more with less (Pauly 2011).

The alternatives listed in this document are grouped into categories, starting with those related to quality, followed by system inputs, including the critical area of insurance, and then on to information technology, payment mechanisms, competition, and cost. Other sequences could work as well. The first draft of this document started with alternatives associated with insurance reform simply because that was the primary focus at the time. The more recommended reforms I identified, however, the less that structure worked for me.

Moving On with One-Sentence Options

If we leave the comprehensive solution to other countries, are we defeated? Certainly not. There are many things that national and state governments can do without the comprehensive solution. Many of the provisions of the ACA could have been passed individually, but that path might have been perceived as requiring more political capital than pushing through one great bundle of provisions.

In the sections that follow, I lay out a number of options. Some already exist in the ACA but may need to be revisited if the law is repealed or gutted. Some fill in gaps left by the bill, whereas others were not addressed during the debate and markups leading to the final version. A few may be original here.

The reforms have been classified into the following categories in the text, in the table of contents, and in the more detailed listing of reform titles that follow the text (which is provided in lieu of an index):

Quality

Access

Universal Access

Incremental Access

Technical Management

Management of Interpersonal Relationships

Continuity of Care

Measurement and Reporting

Motivation

System Inputs

Resource Availability

Personnel

Medical Technology

Money/Insurance

Information Technology

Payment

Fee for Service

Capitation/Vouchers

Bundling

Budgeting/Salaries

Consumer-Oriented Health Care

Pay for Performance

Competition

Antitrust

Labor Substitution

Strengthening Buyer Power

Cost

Cost-Reduction Measures

Malpractice

Fraud and Abuse

Organizational Learning

These topics are interrelated and thus reforms cannot be cleanly segregated into one category or another. For example, electronic health records are key to recommendations related to quality, pay for performance, and information technology. Assignment of a one-sentence action to any given category is likely to be arbitrary. In order to clarify who might be taking a particular initiative, I have added suggested actors. Sometimes the key actor is also named in the one-sentence reform that heads up an item. The interrelatedness of all the categories made selection of the right one under which to place a reform frustrating and indefensible.

I have not tried to select only major reforms. It is common in health policy debates to dismiss a proposed reform because its impact is small. That tendency is different from industrial practice, where improvements are taken regardless of size or immediacy. Industrial managers and those health managers who understand learning organizations know that small changes cumulate over time into large savings and can contribute a great deal to the ultimate outcome. They also know that failure to correct small process flaws over time can culminate in disasters. One way to get this fact across to Americans who emphasize home run hitting is to cite the alternative strategy of small ball, the accumulation of singles, walks, and stolen bases to get runners across home plate. Obviously, this is a false dichotomy, because the most successful teams will employ both strategies, but it illustrates the alternative viewpoints.

Political necessity may limit the number of reforms undertaken at any one time. Observers often talk about political capital, especially during a honeymoon period after a decisive political win with its associated mandate. The election of 2012 did not provide any such window. Political scientists also talk about the focusing behavior of legislatures, which seem able to handle only one major issue at a time. Yet, given the mixed results evident with the comprehensive approach, the one-sentence approach still deserves consideration.

Consistency

Not only are the category assignments somewhat arbitrary, but so are the selections of specific actions. I have made no attempt to present them as part of an integrated solution. In fact, this document does not mean to imply that they are all appropriate alternatives. They are allowed to be in conflict with one another. My objective is to get them out there and to nudge others to take action rather than waiting for a grand solution. There is no claim here to internal consistency in political outlook or targeted outcomes.

Format

Each proposed one-sentence reform is presented first without adornment, often as it appeared in my original blog or as set forth in the ACA as amended. Next I suggest who the key actor(s) would be. Then I briefly discuss the pros and cons associated with the reform as a policy alternative, often incorporating references. Because the health care policy literature is so vast, I have purposely focused in on citations from readily available publications, such as Health Affairs, the New England Journal of Medicine, and the New York Times. I have not tried to be either definitive or exhaustive. One thing this document is aiming for is a cross-sectional picture of what real health care reform would entail.

Where one or more recommended alternatives are intended to accomplish the same end, they are presented under the same reform letter and number with an alphabetical suffix. For example, in Reforms A3a and A3b, nondiscrimination in underwriting is achieved first through the prohibitions set forth in the ACA and then through the Americans with Disabilities Act (ADA).

The revenue side of health care reform has not been addressed, since that would entangle us in a complete review and revamp of the tax code. Wilensky (2012a) suggests a number of bipartisan directions for Medicare reform, including increasing the eligibility age to 67 and more cost sharing and premiums based on income. As she points out, these recommendations would not necessarily affect the cost of care, but they might primarily shift it to other payers. Clearly, more revenue is called for, but presenting the alternatives for generating it would take another document of equal or greater length.

Parallels with the Institute of Medicine's Best Care at Lower Cost Report

There are parallels in this document with the Institute of Medicine's emphasis on a continuously learning health system (IOM 2011). Its report entitled Best Care at Lower Cost (IOM 2012a) emphasizes the following:

• Generating and applying knowledge in real time

• Engaging patients, families, and communities

• Achieving and rewarding high-value care

• Creating a new culture of care

I have gone back and added several one-sentence reforms based on these IOM recommendations. For the most part, the institute's recommendations are at a level of abstraction somewhat higher than that offered here. Because this book is not a consensus report of the type usually put forward by the IOM, I don't have to go to a higher level of abstraction to achieve consensus. I can present opposing alternatives without espousing either. Given the makeup of the working groups it is not surprising that the IOM reports emphasize the long-run possibilities of information technology and place less emphasis on lowering prices or increasing competition to reduce costs.

It is clear that there are multiple visions of the health care system at work here. In his book Oxymorons: The Myth of a U.S. Health Care System, Kleinke (2001) laments the fact that the health care system in the United States, a highly dysfunctional natural system, is not a coherent, engineered system. He cites its fragmentation and conflicting self-interests. These shortcomings make development of a learning health care system an uphill battle, as the IOM reports acknowledge. That is why the final category of this document does not focus on health care system learning, but on organizational learning. At least in an organization there may be accountable leadership, a quality lacking overall in health care.

The Essentials Identified by FRESH-Thinking

The FRESH-Thinking Project, a multidisciplinary research endeavor focused on health care reform (FRESH stands for Focused Research on Efficient, Secure Healthcare), produced a set of published recommendations agreed to by a relatively diverse set of experts, including physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others, and I have attempted to ensure that the reforms presented here encompass most of them (Arrow et al. 2009). In writing this document, whenever I asked myself whether I had covered the important areas reasonably well, I returned to that publication.

WHAT ABOUT THE AFFORDABLE CARE ACT?

The ACA, especially its revenue provisions, is likely to be undermined by the lobbying process and subsequent revisions (Radnofsky and Weaver 2012). It would have made the writing of the one-sentence reforms presented here much easier had I focused mostly on the bill and made up one reform for each section of the act, saying whether or not to try to revive that particular feature should the bill be thwarted.