Obamacare: Quality of care
OBAMACARE: A PRIMER FOR UPCOMING DEBATES >> PART 3: QUALITY OF CARE
Now that the Supreme Court has decided and the election season begins to boil, it seems likely that the Affordable Care Act (ACA), known as “Obamacare,” will be one of the pervasive issues.
It is worthwhile to have an understanding of what Obamacare was supposed to do, what it has done to date, the problems remaining and what could be done now—“the fix.” Health policy issues can be organized by four pillars: insurance coverage, access, quality and cost. In the last issue of TMC Pulse, I discussed access. Today is quality of care. The final pillar, cost, will be discussed next month.
America has great health care, right? Wrong. In fact, America is 51st in the world in life expectancy and 34th in the world in infant mortality. A lot goes into health care indices, and, in fact, it has been estimated that in terms of what determines life expectancy, 40 percent is lifestyle, 30 percent is genetics, 20 percent is public health and only 10 percent is medical care—which is what doctors, nurses, hospitals and patients do. But our medical care is great, right? Wrong. We are the worst out of 18 developed countries in avoidable deaths such as appendicitis, measles, colon cancer and deaths due to heart attacks. Fortunately, we are the best at something: breast cancer mortality. How can this be? Certainly, part of the problem with our medical care and our health care is our lack of health insurance. But even for those with health insurance, we have problems with care coordination, appropriate access to care in terms of the time it takes to see a physician and, for many, high costs that they cannot meet for health care and prescription drugs.
The public assumes we have great quality. In a recent Texas Medical Center Nielsen poll of 1,000 Texans, not one ranked quality as the most important among access, coverage, cost and quality.
What Obamacare Did
The Affordable Care Act created the Center for Medicare and Medicaid Innovation (CMMI), which is to address improvements in both cost and quality. In fact, it has supported important innovations, but unfortunately, few have led to major changes in health care quality. Equally unfortunately, the entire budget for CMMI is $10 billion over five years, which is 0.2 percent of the total Medicare and Medicaid budgets.
The Continuing Problem
Given the fact that Obamacare really did not address health care quality, the same problems that existed before the Affordable Care Act continue. As we have stated previously, current incentives for quality improvement are not aligned. Physicians who are paid fee-for-service continue to provide more services, at least some of which are unnecessary. Hospitals are incented to admit patients by paying for each admission. The federal agency responsible for improving the quality of care to the public is the Agency for Healthcare Research and Quality. This agency reports quality indicators every year and has shown a one to three percent improvement in these quality indicators per year over the last 10 years. Of note, the cost of health care has increased more than double the rate of improvement in quality.
1. | Patients must insist on quality. This means that they must understand quality indicators. The University of Virginia has created a questionnaire called Tailored Educational Approaches for Consumer Health (TEACH) that will place health care consumers into one of eight groups and then customize the health information in a way desired by the individual consumer. TEACH questionnaires must be used so that the half of Americans with an IQ of less than 100 are as informed as the other half. If this were possible, it might be more reasonable to approach health care as a market. Until the information asymmetry is addressed, it is folly to consider health care a market. With better information, it will be reasonable to provide the sorts of incentives that could lead to behavior change and seriously address lifestyle issues such as obesity, smoking and drug abuse. Perhaps a good starting point would be in efforts to reduce patient-induced demand by, for example, having patients pay more for non-emergency visits to emergency departments. Patient understanding will be increasingly important as patients are required to spend more of their own money on medical care.
2. | Promote integrated health systems. My discussion in past issues of Pulse about the value of integrated health systems is important to improvement in quality: new payment mechanisms will improve quality as more patients are likely to get what they need and not more; electronic health records will provide the kind of decision support for how best to help a patient in increasingly important ways over the next five years. Recently, the concept of the Accountable Care Organization has been proposed. This is a specific type of integrated system, and others will emerge. These systems must be promoted by the federal government and by states.
3. | Texas has the largest percentage of uninsured in the country. It is true that 1.4 million of these people are undocumented, but at least 3.6 million are not. We must find ways to improve access to care for the uninsured. This is not only a matter of doing the right thing, it is also a matter of addressing the economic ripple effect caused by paying for the uninsured, including premium rate and tax increases, and ultimately our ability to be competitive in attracting business to Texas. There are a number of proposals that have been made that could use federal dollars to pay for the vast majority of the uninsured. They should be considered carefully, and if they are not acceptable, alternatives must be developed with the same goal in mind.
What does this mean to you? The most important issue a patient or potential patient can tackle is to pay attention to quality. Insist that your practitioner explain what medical problems you have and ask if other practitioners would approach your problem the same way. This is a better question to ask than, “What would you do?” since the practitioner is not you, and you have preferences that may differ from those of the practitioner. On a broader scale, ask your practitioner what you can do to improve access to care for all citizens. It is worth repeating that being uninsured is lethal to them, costly to everyone through increased insurance premiums and higher taxes, and makes Texas