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WASHINGTON, D.C. – At the Digital Medicine Society (DiMe) Healthcare 2030 event on Monday, panelists discussed how reimbursement shapes the course of healthcare.
Panelists weighed-in on what incentive policy or payment model they would change to make the system more sustainable by 2030.
"The problem with the models from CMMI [capability maturity model integration] since the ACA [Affordable Care Act] was enacted was that they are voluntary," said Lee Fleisher, founder and managing partner at Rubrum. "You need to mandate that people be in the models."
Nate Paulsen, vice president of health plan relationships at Oshi Health, said he would like to disconnect commercial insurance from medical loss ratio.
"When your profitability is tied to 15 cents on the dollar, the fastest way to grow your profitability is to grow the number of dollars spent. So, changing that incentive and disconnecting that is really critical to changing the incentives around how we spend and purchase care," Paulsen said.
Jonathan Taylor, vice president of health solutions for Aon said that he would like to see cost transparency for the consumer.
"In a system where we access healthcare through insurance, we need to have a way of defining what cost is and making this easier for the consumer to understand," Taylor said.
Mona Siddiqui, senior vice president of home and community care for Highmark, said that regulations that are in place for home care are a hindrance to providing good care.
"I do think that we need to re-examine some of the regulations around the heavy burden of documentation and regulations around who can do what, exactly at the home because that is a real difference to providing appropriate care," Siddiqui said.
Panel moderator Margaret Malone, principal at Flare Capital, asked the panelists who they think are the actors best positioned to help move from pilot to scale.
Paulsen suggested following the money.
"All money flows to and through the payer, whether that's CMS funds, whether that's employer funds, state funds, it all goes through the payer," Paulsen said.
He added that scaling revolves around whether the payer has the motive to continue to incentivize cost savings at the end of the day.
"A lot of that is driven by the provider and delegating risk to the provider," Paulsen said.
Paulsen said that more investment needs to be tied to reduction in utilization and cost to feeling better, not experiencing symptoms and supporting value-based care.
When it comes to measuring outcomes, Fleisher said, "We don't have a good measure of health that we can say people are getting good outcomes."
With roughly 50% of Americans getting their health insurance through their employer, Taylor weighed-in from an employer's perspective.
Taylor said that employers have to continue to incentivize personal capital and that employers need to lean further into the plan designs they have, particularly larger employers that are self- funded.
"They've got to have a game plan and not just react to the cost increases and whatever the insurance company says or whatever the market says. They have got to have a plan to incentivize and drive health behaviors," Taylor said.
Taylor stressed that HR needs to be empowered to run a business.
Panelists also discussed what new payment models could help enable the transition to value- based care and how CMS is helping or potentially hindering the ability to achieve value- based care.
"Most organizations know that these are three-year models," Siddiqui said.
"From an operational perspective, with all of the investments that are required to make these things successful long-term with all your competing priorities, why would you make a heavy investment in a model that is going to be sun setting in a couple of years? I think that is something we really have to think about–sustainability."
She added that when considering models, it is important to appreciate the amount of operational investment that is required and that may be very different depending on the health system and the scale and size of the health system.
The topic of outcomes and measuring outcomes was also addressed.
Malone asked the panel, what do you think are some of the barriers to measuring value that are most needed to close those gaps?
"If you actually have CMMI, they have two authorities, either for certification, one is that you reduce total cost with no change in outcome, or you have an improvement in outcome with no change in costs. Has any model ever been certified for improving outcome? The answer is no," said Fleisher.
He added that it is really hard to measure health; however, it is easier to measure total cost of care.
"We've measured things that we can easily measure, which has been around for decades. And the hard part is the attributable–who's attributable to what happened," said Fleisher.
He added that there is not a good system to actually assess outcomes.
"What I think we do is we assess cost and use some severance," said Fleisher.
Taylor brought up the topic of whether or not people get adequate access to their personal data.
"We're in this age when there is a plethora of data, but how do we connect that data so that the individual can use that over a span of years," said Taylor.
Siddiqui said that compared to 30 years ago versus now, when looking at the number of measures available, the cost of care has increased at a steady clip in that time period while access and patient satisfaction has decreased.
"I am not sure that measurement is the way to go. I think the basics of patient access and patient satisfaction and total cost of care actually should be sufficient," Siddiqui said.
She added it feels like there is an enormous burden on the system without anybody being happy about it.
"It's not a system that's done well by patients. It's not a system that's done well by the regulators. I just think we have to get back to the basics and have people focus on the things that are really important," Siddiqui said.
Aon's Taylor pointed to a systemic problem in the culture where people do not celebrate taking care of themselves.
Taylor said that as a society individuals wait until there is a problem and then seek care.
"If more people were going to the doctor routinely and proactively, how much better off would we be as a society?," Taylor said.
The panelists gave their opinions on what changes need to be made to health plans and what needs to be done differently to succeed and empower consumers and providers.
"One of the things that we're really wrestling with is the time horizon of savings. We want to get paid for preventative care so we don't get to stage one," said Paulsen.
"But how do you reward, in a meaningful way, that identification process?
That time horizon is probably one of the most underestimated, detrimental components of the ROI calculation for whether or not we're going to do value-based care and we're going to do preventative care."
Paulsen said that having easy, repeatable, trustworthy models that are scalable, that are adaptable to different categories and that are predictable is something that's missing in validating innovation solutions.
