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How BRCTs can help solve our health care problem and fix the ACA
January 11, 2017
With incoming President Trump and Congress poised to dismantle the ACA and replace it with something yet to be determined, the question is how to build a health care delivery system that is both effective and efficient, and one that can be endorsed by both political parties, patients, doctors, and large medical organizations like AHIP, AHA, and physician lobbying groups. Despite the antagonistic rhetoric uttered by Democrats and Republicans, certain broad concepts are advocated by virtually all parties that would be impacted by medical reform, and it is sensible to focus on those when constructing a new health care delivery framework. They include:
Improving the quality indicators by which doctors, hospitals, and long term care facilities are judged to make them more reflective of patient preference and clinically relevant outcome measures individualized for each patient.
Reducing the nearly one trillion dollars of squandered medical dollars by curtailing low value care and over-treatment and promoting high value care.
Encouraging more transparency of medical information and cost that can facilitate shared decision making and patient-centered care, thus allowing patients to engage the health care system in more of a free-market environment.
BRCTs, which promote rational and patient-centric decision making, can help realize each of these goals in a way that leads to a reduction of wasteful spending and an enhancement of patient satisfaction. Everything begins with the doctor-patient interaction. Currently doctors are paid more to perform procedures than to do the hard work of guiding patients down a sensible path of medical decision making. Doctors and patients also have few tools with which to engage in meaningful discussions, and patients are often bombarded by medical data that is both distorted and confusing. These realities trigger the proliferation of wasteful care that is now crippling our health care delivery system.
Medical reformers use the words “quality” and “value” to describe how they are attempting to alter physician pay to encourage more sensible behavior. A doctor’s “quality” is derived by his/her ability to achieve certain benchmarks that are defined by Medicare and other insurances. These may include prescribing statin cholesterol medicines, lowering blood pressure below a specified number, ordering mammograms, and prescribing specific medicines for certain conditions. Those doctors that generically compel their patients to blindly agree to “quality” interventions that insurances like Medicare have scripted will be rewarded with more pay, those who are less rigid and do not merely check off the “quality” boxes will be hit by pay cuts. Multiple groups, such as Care that Matters, have studied many guidelines and have found them to have dubious medical validity. Some even could be harmful if taken to an extreme, such as drastically lowering blood pressure in a frail elderly person. Similarly, many costly interventions that could impact health outcomes negatively are not included in the quality guidelines, including the use of stents in asymptomatic heart blockages, the use of bone density medicines for long duration, and several expensive orthopedic procedures and tests shown to have no value. BRCTs would be ideal vehicles to revamp current clinical guidelines and promote more cost-effective and patient-centric quality indicators. By clearly delineating the absolute risks and benefits of medical interventions in a simple language, BRCTs allow doctors and patients to together ascertain which drugs, tests, and procedures make sense. They can be individualized and can spark a conversation between doctor and patient as to the “quality” of an intervention for that particular patient. By encouraging doctors to discuss actual risks and benefits with patients to reach shared decisions, then not only will true quality be achieved, but over-treatment can be curbed. BRCTs make such discussions simple, and the achievement of quality will lead to reduction of unnecessary cost.
Value is the other part of the formula being used to judge doctors. As Atul Gawande and others have shown, many routine and highly-compensated medical interventions confer very little value to patients, and some can cause harm. The proliferation of low value medical care has led to the nearly one trillion dollars spent annually on unnecessary medical interventions. Any plan to succor Medicare and to revamp the ACA, any plan to reduce insurance premiums and to expand health care coverage, must be contingent upon improving health care value. Currently Medicare pays doctors based on a formula derived by a small non-transparent committee in the AMA. The basis of this formula is not related to the value of the intervention. In fact, many interventions that have low medical value are paid at far higher rates than those of high value. For instance, a cardiac stent when placed in a heart artery where it has been shown to cause more harm than good is paid at a far higher rate than a comprehensive medical visit that addresses the risks/benefits of the stent and then helps the patient achieve better heart health through proven and less costly interventions. For true value to be achieved, and financial squander in the health care delivery system to be curbed, we need to base physician pay on true value, something with which all health care reformers and insurance companies would likely concur.
BRCTs are a facile way to achieve such high value care. A BRCT of a stent, for instance, demonstrates its lack of value, while BRCTs of the use of statins and aspirin in heart disease, as well as of smoking cessation and exercise, show that they have tremendous value. Longitudinal studies, consensus statements by such groups as US Preventive Service Task Force, and insurance company research have shown us the value of many interventions, all of which can be put in the form of a BRCT. When done this way, a true value-based payment system can be constructed, and this will incentivize health care providers to promote high value care. Currently just the opposite is occurring.
All of this will help to make the health care delivery system more like a free market, something advocated by Republicans like Paul Ryan, and by many progressive leaders who support a patient-centric approach to care. What is a free market in health care? In a recent op-ed I wrote in the Washington Times, I argue that a free market occurs when patients have the capacity to understand the actual value of medical interventions, and then to have the capacity to choose the tests, medicines, and procedures that are most beneficial to them. Such free market behavior cannot exist until patients have access to accurate and easily understood medical information. Currently patients are deluged by inaccurate medical data through the media, pharmaceutical ads, and physician advice. The latter source is most concerning, since physicians often obtain their medical facts from deceptive relative risk/benefit numbers, and since physicians are often rewarded to be more aggressive even when other alternatives are medically superior and less costly, something that prevents them from being reliable sources of accurate medical data for patients.
Again, BRCTs are ideal vehicles to deliver meaningful medical information to both patients and doctors, allowing patients to make free-market decisions. Encouraging BRCT use in the media, in electronic medical records, in doctor-patient interactions, and in easily-accessible websites will provide patients with the tools they need to make rational decisions. Because BRCTs use no numbers and thus are simple to interpret, because they are understood by people with all levels of literacy and who speak any language, and because they demonstrate risk and benefits of interventions clearly and accurately, they empower patients to be vibrant participants in the health care marketplace. Even as some free-market advocates argue that patients must be privy to the cost of procedures and have some financial skin in the game, even as they claim that privatization of health insurance is needed, the simple fact is that patients cannot be part of a free market unless they understand how interventions impact their health. Where progressive and conservative reformers converge, and what insurance companies already understand, is that the formula for health care success both financially and medially must be patient-centered. This can only occur when quality, value, free-market, and patient choice are not merely words, but rather are data-driven tools used to transform our health care landscape.
It is clear that the ACA is going to disappear. I argue in RealClearHealth that the dysfunction of our health care system, and the increase in health care premiums, is not caused by the ACA. Despite its many flaws, the ACA has helped to expand insurance coverage to millions of Americans, and this benefits not only those who now have health coverage, but also insurance companies, hospitals, physicians, and virtually all participants in the health care delivery. The most salient deficiency of the ACA is that it did nothing to alter our dysfunctional health care environment. It did not promote real quality and value, because it did not reward and encourage sensible health care decision making. Medicare reform has fallen into the same trap. By enabling the status quo, health care reformers continue to promote low value, low quality health. BRCTs open a window to something much more effective. While just a simple tool, it is one with the power to drive profound and beneficial change. We need to be responsible and bold when designing a replacement for the ACA, and we need to work together upon the shared ground of high-value low-cost care and patient-centered decision making. Only then will we be able to construct a health care delivery system that is beneficial to all Americans.