At a time of massive changes in the U.S. healthcare delivery system, and also at a time of potentially major healthcare policy changes coming with the new year, it might be good to step back a bit and look at the U.S. healthcare system from an international perspective—and to consider some aspects of healthcare IT in that context as well.
The good news, according to a just-released Commonwealth Fund study, is that, as the online introduction to the study notes, “A new survey of adults in the U.S. and 10 other high-income countries finds that fewer Americans are reporting that cost is a barrier to getting care. In 2016, 33 percent of U.S. adults said they did not fill a prescription, see a doctor when sick, or get recommended care because of the cost, down from 37 percent in 2013. Adults with incomes of less than $25,000 per year saw a particularly large decline of 8 percentage points. These findings align with other national studies showing that the rate of cost-related access problems has been falling, particularly for lower-income Americans, since the implementation of the Affordable Care Act (ACA).” (The full study can be accessed here.)
And that is very good news. Now for the bad news. As the study’s authors note, “Despite these gains, however, the new study reveals that the U.S. still has a long way to go compared to other high-income nations. Only 13 percent of adults outside the U.S.—and just 7 percent of adults in the U.K. and Germany—report a cost-related access problem.”
The authors state that “There are a few explanations for why we remain an outlier. First, although the ACA extended health insurance to more than 20 million Americans, there are still approximately 28 million uninsured (8.9 percent of the population). In contrast, all the other countries surveyed provide universal coverage, accomplished in a variety of ways—from a single-payer system in Canada to a mandatory private insurance system in Switzerland. The result is the same: a very small or nonexistent uninsured population. Second, coverage in these countries tends to be more financially protective than it is in the U.S. For example, many countries have introduced annual caps on consumer cost-sharing such as deductibles and copayments. Some provide exemptions for high-value services like primary care or for high-need groups like those with chronic conditions. In contrast, the average deductible for Americans with individual, employer-based plans reached $1,541 in 2015—which would be nearly unheard of in most other wealthy nations. Finally,” they note, “prices for health care services tend to be significantly higher in the U.S. than in other countries, including for prescription drugs, tests, procedures, and physician visits. These higher prices both drive up health insurance premiums—resulting in more uninsured—and mean that U.S. patients are particularly disadvantaged when paying out-of-pocket for care.”
And of course, there’s this: as the study’s authors note, “President-elect Donald Trump has promised to repeal the ACA. An analysis by the RAND Corporation has shown doing so would increase the number of uninsured by 20 million. It also would increase average out-of-pocket costs for individual market enrollees by $1,500. While it is still too early to make predictions about where the Trump administration will take U.S. health care, closing the gap with other countries will require building on our progress, not reversing it.”
So—without getting into the politics of this, let’s ask, how can we as a nation move forward both to give the largest number of Americans access to affordable healthcare, while also improving both the clinical and financial outcomes of the care delivered? As everyone in the industry knows, policy and payment incentives have been shifting towards population health management as a key overall strategy for curbing healthcare costs and improving outcomes—with the understanding that, so often, improving outcomes does also further lower costs. And there are several critical-success factors that everyone who is pursuing population health management strategies, whether in the context of federally sponsored or private insurer-sponsored accountable care organization (ACO) development, is learning. Among these: rigorous and robust population health risk assessment processes, followed by the in-gathering of those patients/plan members/enrollees into care management programs—with the concomitant development of multispecialty team-driven care management for those same individuals. Intensive and truly leading-edge data analytics are needed for this, as are information systems that provide physicians, nurse case managers, and others, with dashboards to evaluate the fluctuating and evolving health status of patients in these programs. What the pioneers are also learning is that communications infrastructure—including, but not limited to, alert systems that convey where a patient has received or is receiving care, to all the appropriate stakeholders (such as, for example, a patient’s ED visit or inpatient admission being communicated to that patient’s primary care physician, care manager, and all others who need to know about such developments), and also communications systems that allow patients and their physicians and care managers to securely message with one another, that facilitate optimized appointment scheduling, and that communicate status changes and other vital information to all stakeholders (including, as appropriate, between payers and providers and patients/plan members), as well as, of course, authentic health information exchange—all of these and many more, will be needed going forward.