Implementing Transparency to Address our Health Care Challenges

Implementing transparency to address our health care challenges and solve the long term debt challenge

"Rising healthcare costs and their consequences for federal health insurance programs constitute the nation's central fiscal challenge"

Congressional Budget Office

The deficit and the debt debates have rightly focused on the role that health care expenditures play in the fiscal long term threat to the United States. The focus on targeting the cost drivers, takes greater urgency as we are revisiting of the disastrous deficient and debt debates. Bending the curve of the US debt is essential to contain the escalating the US debt.

As the debate over how best to reform our wasteful health-care system continues, there is one measure we can implement immediately to improve quality and rein in runaway costs—the public release of data from the Medicare program, as required by a provision of the Patient Protection and Affordable Care Act and other public reporting requirements for the health care sector.

The Republican house has made good on their pledge to repeal the Obamacare (Patient Protection and Affordable Care Act, AKA “Obamacare) with 37 votes in the house and now threaten to hold hostage the economy and government with upcoming debt ceiling and budget debates. Their concern about the impact of health care costs on our escalating national budget is understandable; however, repealing “Obamacare” as a remedy will be unfortunate. Additionally their concern about the growth of government and its impact on the health of all Americans is understandable. Within the 2700 pages of the legislation, are provisions that will reduce the escalating cost of healthcare to individuals, business, and the nation. Additionally, implementing Obamacare has the potential to address a number of additional challenges facing our healthcare system: The quality and safety of healthcare services, expanding the number of Americans who are insured, as well as access to medical care. Implementing the following three sections of Obamacare will contribute to making The US healthcare truly the best in the world at an affordable cost. Leveraging the provisions of the new health care legislation, a citizen based civic engagement a road map built on demand for accountability of stakeholders, transparency and performance reporting, encouraging organized care, reforming the malpractice system, supporting research on evidence-based care, targeting fraud and abuse is offered.

This article presents an activist citizen driven agenda to insure that we implement the provisions of the law to build a more reliable healthcare system that provides access to safe, high quality health care at an affordable cost to the individual, businesses and the nation. And more importantly, what can be done to contain the cost of healthcare, costs that are likely to increase regardless of how successful either party is to get their way. It is in finding ways to contain the costs of health care that the politicians have been lacking. It is not as if there is a lack of ideas on how to contain cost and improve quality, it’s the ability to frame the question in the proper manner.

Sec. 3015. Data Collection; Public Reporting,

Data Collection; Public Reporting

A provision contained with Section 2718 of the Patient Protection and Affordable Care Act (ACA) contains a requirement for all U.S. hospitals to make charge information publicly available. This provision specifically states:

“Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886 (d)(4) of the Social Security Act.”

What if rather than focusing on comparing hospitals based on various measures, we challenge ourselves and ask what can we do to make all hospitals top hospitals?

What if rather than listing all the barriers we accept that public reporting is as The Society of Thoracic Surgeons “believes the public has a right to know the quality of surgical outcomes and considers public reporting an ethical responsibility of the specialty”.

What if rather than hospitals spending millions of dollars advertising their US News ranking they build on the "Philadelphia Plan", that Chas. Scott Miller, M.D., , proposed in 1917, in which he laid out the foundation for the standardization of hospital statistics?

Start with Public Reporting: More Transparency, Better Health Care

I am firmly committed to the idea that we need to do a better job measuring costs and measuring quality before we can begin to have effective cost control policies. That is because until we can differentiate between productive and unproductive care, while most cost control measures will be able to reduce overall spending, they will not be able to do so without harming the quality of our care or limiting our access to the type of services we now expect.

Efforts by government, insurers, foundations and consumer groups have had only a limited impact. Citizens engaging with and holding local healthcare institutions accountable for outcomes related to treatment mistakes may have a greater impact. Pressure on insurers and other health care players to simplify and standardize the administrative process associated with healthcare can make health care encounters more user friendly and less expensive. Coordination of care of patients leaving the hospital thus preventing costly and unnecessary readmissions.

Individual healthcare decision making lacks information about quality and outcomes. I most cases you may do far more research and knew far more about the mini-van I was going to buy when my child was born, than I did about my delivery options or the ob-gyn who was going to deliver your child!

You can’t affect what you don’t measure. Add in the variable of cost and you can get to a measure of value, and of course subsequently, measures like QALY.

Develop ways to measure the performance of the healthcare system, providers, etc. Building on existing programs that work we must find scientific methods to estimate physician performance. An intergeneration effort, utilizing sophisticated scientific measures to define quality and measure it we can create a framework to define quality and allow for physician autonomy. A recent article by Michal Porter in the Harvard Business Review, provides examples for specific providers who understand their costs and measure their performance.

In a recent article that appeared in the WSJ, George P. Shultz , Arnold Milstein and Robert Krughoff suggested the importance of public reporting in addressing the waste and cost on the us healthcare.

The Affordable Care Act includes a provision that would greatly advance the power of measurement and public reporting. It requires that Medicare release claims data—with full protection of patient privacy—to qualified organizations that can analyze the data and publicly report on hospital and doctor performance. Originally championed by then-Sen. Judd Gregg, a Republican, and then-Sen. Hillary Clinton, a Democrat, this provision has bipartisan roots.

These provisions mandate that outcomes be published.

Transparency in Comparative Value of Clinicians

Paul B. Ginsburg discussed how transparency for price and quality of services of providers has the potential to further efficiency and improves quality of care. However, he suggested that the near-term potential of these steps have been oversold. He described patient use of quality data as stymied by the dual lack of awareness of quality variation among providers and the complexity of combining numerous process measures of quality into an overall score. Continuing, he spoke of how a large impact of price transparency was dependent on provider payment reform and the insurance benefit structures that provided incentives for patients to choose more efficient providers.

Transparency in Comparative Value of Hospitals and Integrated Systems

Peter K. Lindenauer asserted that greater transparency of hospital quality and price information might improve the value of hospital care by catalyzing hospital improvement efforts, price competition, or patients’ choice of better institutions. However, he indicated also that evidence is currently limited on the potential of transparency to lower costs. He suggested public reporting of readmission, complication, and healthcare-associated infection rates as offering the best hope of simultaneously lowering costs while improving the outcomes of care. Extrapolating from the benefits of the New York State Cardiac Surgery Reporting System, he presented estimates that this strategy could result in as much as $5 billion in annual savings, and might be strengthened by linking hospital payments directly to performance. He additionally suggested that while there is limited evidence for the benefits of transparency on hospital outcomes, assigning savings to transparency could be inherently problematic at some level, since reporting initiatives provide the stimulus for changes in care, but do not directly change care itself.

Transparency in Comparative Value of Insurance Companies

Margaret E. O’Kane posited that while quality transparency has stimulated gains in the quality of care delivered, significant gaps in reporting and accountability remain. She cited the percentage of patients in accountable health plans that receive a beta blocker after a heart attack as rising from 63 percent in 1996 to 98 percent in 2006. However, these improvements have been limited to the part of the industry that has either voluntarily focused on quality or been pushed into accountability. Identifying a number of reasons for this partial success, she suggested that, as healthcare costs have ballooned out of control, purchasers have increasingly selected plans based on cost of premiums or best provider discounts; many private purchasers have not rewarded high performing plans; consumers often have few or no choice of health plans; and many health plans have been ambivalent about their role in quality.

Legal aspects related to public reporting

The enactment of the Affordable Care Act of 2010 created a new context for public reporting initiatives by framing a national strategy for quality improvement, including through public reporting.

The Affordable Care Act directed the secretary of HHS to establish a national strategy for quality improvement that includes public reporting of performance information through health care quality websites. CMS and AHRQ were required under the law to convene multi stakeholder groups and develop performance measures tailored to the needs of "hospitals and other institutional health care providers, physicians and other clinicians, patients, consumers, researchers, policy makers, states, and other stakeholders." The resulting performance measures were to include clinical conditions, to be provider specific, and to be detailed enough to meet the needs of patients with different clinical conditions.

The Affordable Care Act also called for public reporting of performance measures on quality, cost, and other metrics. Public reporting will be used for insurance plans that will be offered through new state-level health insurance exchanges starting in 2014. Reports will also be prepared on hospitals, physicians, and other health care providers who participate in Medicare's new "value-based purchasing" program, which will base hospital payment in part on whether providers achieve targets for delivering higher-quality care. These performance data are also to be posted at www.healthcare.gov. For Medicaid, the law required HHS to adopt an initial core set of quality measures; develop a standardized format for reporting by states; and make the information publicly available annually, beginning in 2014.

FEDERAL ACTIVITIES: Two federal agencies within the Department of Health and Human Services (HHS) share primary responsibility for these activities: the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS). AHRQ supports research and works with public and private stakeholders to develop quality measures, report aggregate national- and state-level data, and conduct research on the science of public reporting. It does not, however, report measures at the provider level.

CMS collects data on performance measures from providers participating in the Medicare, Medicaid, and Children's Health Insurance Program. CMS posts comparative provider-specific information about hospitals, doctors, nursing homes, home health agencies, and kidney dialysis facilities at www.healthcare.gov. The amount of information CMS posts varies by type of provider.

The most information reported at the national level is for general hospitals and, as noted, is available at www.hospitalcompare.hhs.gov. Since 2005 this site has reported on quality measures focusing on heart attack, heart failure, pneumonia, and surgical care for all US acute care hospitals. The Hospital Compare website also includes measures developed from patient surveys in such areas as communication with doctors and nurses, responsiveness of hospital staff, pain management, cleanliness and quietness, and instructions about medications and discharge.

CMS also maintains www.medicare.gov, which provides information allowing consumers to compare the Medicare Advantage and Part D drug plans available in their area. (See the Health Policy Brief published June 15, 2011, for more information on Medicare Advantage plans.)Sec. 3015. Data Collection; Public Reporting

This section would amend PHSA Title III by adding at the end the following new PHSA

Sec. 399II, Collection and Analysis of Data for Quality and Resource Use Measures. This section, as amended by Sec. 10305 of PPACA, would require the Secretary to establish and implement an overall strategic framework to carry out the public reporting of performance information, as described in new PHSA Sec. 399JJ, as added by this Act. In addition, the Secretary would be required to collect and aggregate consistent data on quality and resource use measures, and may award grants or contracts for this purpose, and to ensure that data collection, aggregation and analysis systems involve an increasingly broad range of patient populations, providers, and geographic areas over time.

This section would allow the Secretary to award grants or contracts to eligible entities to support new, or improve existing, efforts to collect and aggregate quality and resource use measures. The Secretary, under this section, would only be permitted to award grants or contracts to entities that enable summary data that can be integrated and compared across multiple sources. This section would authorize the appropriation of SSAN for FY2010 through FY2014.This section would also add a new PHSA Sec. 399JJ, Public Reporting of Performance Information. This section would require the Secretary to make available to the public, through standardized websites, performance information summarizing data on quality measures. This performance information would be required to include information regarding clinical conditions to the extent such information is available, and the information would, where appropriate, be provider-specific and sufficiently disaggregated and specific to meet the needs of patients with different clinical conditions.

This section would require the Secretary to consult with the entity with a contract under SSA Sec. 1890(a) and other entities as appropriate to determine the type of information that is useful to stakeholders. In addition this section would require the entity with a contract under Sec. 1890(a) to convene multi-stakeholder groups to review the design and format of each website and to transmit the views of these groups to the Secretary. This section would authorize the appropriation of SSAN for FY2010 through FY2014. As nonprofit institutions, health care systems, insurers and community health care centers have important fiduciary obligations to provide benefits to their communities commensurate with their tax exempt status.

Community benefit standard

Section 9007 of the Patient Protection and Affordable Care Act , creating a new 504(r) of the Internal Revenue Code, lists “Additional Requirements for Charitable Hospitals,” to increase the accountability and “charitability” of tax exempt hospitals. How will these requirements be met? Engage with health care organizations in developing a consensus regarding community benefit reporting.

Physician Payments Sunshine provisions

One often-overlooked provision is Section 6002, which requires the public reporting of payments or other value transfers made to physicians and teaching hospitals by manufacturers and group purchasing organizations of drugs, devices, biologicals, and medical supplies that are covered by Medicare, Medicaid, or the Children’s Health Insurance Program.

June 24, 2019 Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First Announces plans to increase price transparency to encourage patients to shop for health-care services via: (1) requiring hospitals to publicly post both charges and negotiated payment rates for selective services, (2) consideration of a rule to inform consumers of their possible out-of-pocket costs to patients, and (3) expand use of high-deductible health plans, and use of HSAs, by increasing the amount of HSA funds that can be rolled over to the following year, and permitting funds to be used for direct primary care (also known as concierge care) and health-care-sharing religious ministries Rule released on Nov 15, 2019, requires hospitals to make public all charges and negotiated payments, for at least 300 selected services; on Nov 15, 2019, the administration released a proposed rule that would require insurers to provide information about cost-sharing to enrollees.

Conclusion:

Implementation of the provisions of the Patient Protection and Affordable Care Act offers an opportunity to transform the US health care system and with it to shape the character of the US for the coming decades. Leveraging the provisions of the new health care legislation, a road map built on demand for accountability of stakeholders, transparency and performance reporting, encouraging organized care, reforming the malpractice system, supporting research on evidence-based care, targeting fraud and abuse is offered.