Friday, October 30th, 2015
The Patient – Honoring Choices
Dave Racer, MLitt and Lee Beecher, MD, DLFAPA, FASAM
How are patients going to retain choice in medical decisions and over the quality of their own care? Which ‘system’ of care and payment processes best meets the needs of individual patients?
The Twin Cities Medical Society expended time, resources, and intellectual power in promoting individual choice for “comprehensive advance care planning program[s].” This important program expresses a key feature that should be of first priority in all healthcare reform efforts. Did the sentiment of honoring patient choice match the Congressional bill authors’ intent in the Affordable Care Act (ACA)?
Thanks to ACA’s expansion of Medicaid, governments are at least modestly reimbursing medical facilities for a good number of low-income individuals for whom charity care had previously been the norm. Add to that, reimbursements are now paid on behalf of some number of the middle-income patients who had previously gone uninsured. Concerning both low- and middle-income patients, however, the ACA’s solutions fall woefully short of the primary question – does the patient maintain choice?
Recently, the Minnesota Department of Human Services eliminated UCare as a Medicaid provider. DHS’ decision took choice away from 360,000 individuals, a great number of whom belong to immigrant communities. Those UCare enrollees are losing access to their preferred physicians. UCare has been very popular among immigrant groups who want to maintain access to culturally sensitive physicians. Clearly, these individuals have lost choice in the new, Minnesota/ACA world.
The Physicians Foundation’s 2014 survey of physicians found that “… 38% of physicians either do not see Medicaid patients or limit the number of Medicaid patients they see.” Low-income individuals on Medicaid may now be enrolled in a health plan, but still may lack access to ambulatory care.
The challenges faced by middle-income individuals going forward, however, are also very formidable. Health insurance premiums paid during 2014 and 2015 spiked higher each year. Now, in 2016 enrollees face 14-49 percent premium increases on plans offered by BlueCross, Blue Shield of MN, HealthPartners, Medica, PreferredOne and UCare. There are really no other choices for patients who purchase their own insurance.
“Mark Dayton blamed health plans for the rate increases, saying that if they make coverage unaffordable Americans will demand ‘that they be removed as the providers of health insurance.’” Insurance companies blame the high cost of care, and the rapid increase in high cost claims as a result of the ACA.
MNsure’s interim CEO Allison O’Toole claims the new premiums will still be affordable because federal taxpayers will pay an increased share of the premium. The health plans that patients are choosing, however, often have high deductibles and out-of-pocket expenses. The effect of the expensive ACA health plans means most individuals covered by non-government health plans face potentially unaffordable health care. Insurance carriers will collect expensive premiums from individuals who will seldom use their insurance for medical care.
Patients have only a handful of insurance companies from which to choose. The ACA’s mandatory benefits and onerous regulations have managed to reduce competition among health plans, except on price and networks.
The ACA promotes consolidation of physician, hospital, clinical, and affiliated practices into large provider systems. These voracious systems, expanding through mergers and acquisitions strive to increase their market share, while consigning enrollees to a network of providers who have signed employment contracts or agree to participate in restricted provider networks. Although the ACA often denotes physicians as key members of a clinical healthcare team, all “providers” are under the close scrutiny of data collectors and number crunchers (be these in-house or external) who ultimately must bend to state and federal rules and officials.
The new mega-models are built on common goals – to capture as many patients as possible for as long as possible, and capture the dollars that follow the patients. Do these organizations offer patients more choice over their own healthcare? Can patients choose from among a variety of physicians, facilities, products, services, and prescription medicines, or are they captured by the system that holds their “membership?”
Some contend that patients retain choice because they are free to go outside of their network, HMO, or ACO any time they wish. When a majority of medical professionals work for a small number of large provider systems, however, it provides limited choices. True, federal law allows Medicare fee-for-service recipients to go to any willing provider, yet the trend toward merging providers and payers into restrictive systems is quickly becoming the new normal. Patients are then strapped with exorbitant out-of-network cost-sharing. In reality, except for wealthy individuals, the patient in these large systems are its captive.
Recent data suggests that ACOs are not delivering hoped-for cost reductions. As the government further reforms ACOs, will patients retain much or any real choice about who cares for them and what care they receive?
The ACA needs major reform and there will be a rigorous debate during this election cycle. As a high priority for voters, Minnesota and congressional policymakers need to empower patients and families with real choices in a real healthcare marketplace.
Here are three priority questions:
1. What reforms would give Minnesota healthcare consumers and taxpayers easy access to prices and details of coverage so citizens can shop for health care services and third party coverage (cost and coverage transparency)?
2. Which healthcare funding systems best respect the needs of individual patients in Minnesota? How do proposed state and federal reforms engage patients and their families to have “skin in the game” in managing their own health care?
3. How can we assure that Minnesota taxpayers and policymakers are able to evaluate the performance and administrative costs of public managed care systems?
Without reform, the ACA will lead to a federal government-run system that over time, will evolve into the “single payer” system embraced by so many. We contend this will produce yet another mistaken answer to a complex problem. Already, the ACA has established government hegemony over what goes on in the exam room and overtly influences a physician’s clinical recommendations and decisions. Would more government oversight improve patient care and create more choices?
Physicians who chafe at government and Third Party Payer control of bedside care surely cannot believe that governments will somehow more efficiently and effectively run the whole system. Medicare and the VA system are single-payer entitlement payment systems, but they too cry out for reform.
The California OneCare Coalition, which passed single-payer more than once, although vetoed by its governor, showed tremendous faith in government. OneCare adherents’ asserted physicians would love it. Doctors, OneCare claimed, will no longer have to deal with insurance carriers and other types of reimbursement systems, fighting for peanuts from all the payers. Instead, OneCare asserted that physicians would be happy with their contracts negotiated with government’s healthcare system managers. Is this a desirable future for Minnesota’s physicians? Hopefully not.
We believe that whatever systems American policymakers enact, the best of them will engage patients and physicians in partnership for better health care outcomes – ultimately honoring the wishes and needs of the patient. Health Savings Accounts (HSA) are a good way for patients and families to fuse healthcare decisions with value and methods of payment. The HSA mitigates first dollar care costs before the high deductible insurance kicks in. Patients who pay part of the bill out of his or her pocket are empowered to ask, “Is this necessary?” and “How much does this cost?” Then the vital physician-patient dialogue bears fruit and patients have choices.
This article appears in MetroDoctors, The Journal of the Twin Cities Medical Society, Volume 17. No. 6, 2015, November/December 2015