2017 has been a roller coaster of a year for health care in the United States. Although the Republican Party’s attempts to repeal and replace the Affordable Care Act have so far failed, the health care landscape in the United States remains in flux and reforms are still needed. General Surgery News asked four surgeons about some of the key issues in health care and what the future may hold.
Participants
President and CEO of Wake Forest Baptist Medical Center, in Winston-Salem, N.C.
Chairman of the Department of Surgery at Hackensack University Medical Center, in Hackensack, N.J.
Surgeon in the Division of Trauma and General Surgery, Marin General Hospital, Greenbrae, Calif., and president-elect, San Francisco Medical Society
Practicing general surgeon and senior fellow in the Center for Health Policy Studies at the Heritage Foundation, in Washington, D.C.
GSN: After the failed repeal and replace efforts, how should we move forward and continue to improve health care in the United States?
Dr. Maa: In the aftermath of the defeat of the Senate’s “skinny repeal,” perhaps our nation should heed the advice of Sen. John McCain [R-Ariz.] and begin a bipartisan conversation to repair the challenges being faced by the ACA. We should remember that the original vision for health care reform championed by former Sen. Ted Kennedy [D-Mass.] had been a two-part process. Part 1 was to get as many Americans into the coverage pool to provide them with access to basic care and limit the costs of catastrophic illness. Part 2 was to reform the health care delivery system, and to derive financial savings and efficiency that would make part 1 sustainable. But the 2010 midterm elections and the Supreme Court challenge derailed all efforts during the Obama administration to move to part 2. The time has arrived for the United States to listen to Mr. McCain, and fulfill the original intent of his colleague Mr. Kennedy. Our nation cannot move backward. We must now move forward.
Dr. O’Shea: In terms of an ideal policy to pursue, value-based health care would require legislation that includes incentives to move away from fee-for-service and toward alternative payment models. But we need a better infrastructure to make this transformation: robust performance measures, access to usable data and access to viable alternative payment models. Currently, I don’t think that infrastructure is in place, especially in terms of alternative payment models. The risk is that we may push providers out of fee-for-service and force them to fit into a limited number of models that may be professionally and financially unrewarding. One option is to incorporate private sector models, especially the innovation in Medicare Advantage into MACRA [Medicare Access and CHIP Reauthorization Act of 2015]. This is something that the Centers for Medicare & Medicaid Services is considering in the current MACRA implementation rules.
GSN: Where is the United States with MACRA implementation?
Dr. O’Shea: MACRA is a very different political animal than the ACA. The ACA was passed along party lines, but MACRA had broad bipartisan support, with 92 senators and 392 representatives voting for the legislation. Therefore, there is broad bipartisan interest in seeing that MACRA implementation is successful. Although ACA repeal-and-replace efforts have consumed most of the health care reform oxygen, what happens with MACRA implementation is likely to have a much more profound effect on the health care system and the practice of medicine.
Dr. Karpeh: MACRA is an effort to increase attention on quality and outcomes in health care. I think the trend to align quality with reimbursements will continue regardless of what happens with the ACA. But the rollout of MACRA is complicated. There has been a great effort to ease it into our workflow. At the moment, physicians have the option to pick what quality metrics they want to follow, so there is a lot of flexibility. In addition, penalties won’t really go into effect into 2018 or 2019, but individual provider outcome data are being collected now. The American College of Surgeons has made efforts to inform surgeons about what they can do to participate in MACRA, although these guidelines only apply to surgeons caring for patients with Medicare.
Dr. Freischlag: Being able to comply with MACRA is a worry. There’s concern that if physicians don’t follow everything, we may not get paid. Although it’s good to be held accountable, I’m not sure everything they ask us to do is important. Some of the measures have improved patient care and length of stay, but others have not. If we truly believe everyone deserves health care, we need to try to figure out a way to fund and provide care for everyone. But there’s no question that people need to adopt a healthier lifestyle. There will never be enough money to provide high-end care if everyone is getting sick.
Dr. Maa: The arrival of MACRA was a mixed blessing for the field of surgery. On the positive side, it brought an end to the sustainable growth rate formula, which had attempted to limit the growth of physician reimbursement and consumed significant resources and time of organizations to overturn. On the other hand, the sweetener needed to convince legislators to repeal SGR was the Merit-Based Incentive Payment System (MIPS), and the opportunity to utilize value-based purchasing, quality improvement, meaningful use and other measures to modify physician reimbursement. While these activities are worthwhile individually on their own merit, it is likely premature at this time to try to create a complex formula combining these activities to adjust physician and hospital reimbursement. The efforts with MIPS are hampered by a lack of consensus of a definition about “value,” the evolving metrics to rate quality, and a lack of transparency about the true costs or “price” of medical care. Instead, the logical next step now would be to accumulate data in these domains in the upcoming years, and analyze them carefully to ascertain whether a reliable and meaningful system to modify physician reimbursement is feasible.
GSN: How will physicians deal with further cuts to National Institutes of Health and other funding sources?
Dr. O’Shea: In the short term, cuts would affect academic medical centers and institutions that strive for cutting-edge research. In the long term, these cuts could affect physicians and patients. But how do you predict or gauge the effect of a research breakthrough that could have happened with more funding, but didn’t? Although the president’s budget called for cuts, most members of Congress do not agree. Hopefully, as we move into 2018, support for medical research will continue along with accountability for how that money is being spent.
Dr. Maa: Cuts to the NIH and other federal agencies will hamper research and innovation in medicine. The United States has historically led the world in medical research, and has collected more Nobel Prizes in Physiology and Medicine than all of the other nations in the world combined. Physicians will likely need to focus on clinical revenue to offset research time, industry support for ongoing research activities, and philanthropy from charitable organizations and individuals/foundations to support new lines of inquiry.
Dr. Freischlag: We’re still trying to figure out how to cost-save while providing innovative care. We want to continue to discover things, but how do we keep doing that when we want to curb costs? We certainly don’t want to wake up 10 years from now and say we haven’t advanced the field compared with a decade ago. For surgeons, we need to know how much care to offer. Do you offer an operation to every patient, even if you know the potential to improve quality of life is low? If there’s only a 10% chance a procedure will work, is it worth it? We ultimately want to help patients, but sometimes there is no right answer. That is why we need to use the outcomes data we do have to assess the risks of different treatments and inform patients of the realities of these options.
Dr. Karpeh: Cuts to science funding have had several repercussions. Many physicians at the NIH have left and moved into the private sector. The cutbacks have also put a noose on novel research ideas. As a result, we may face less innovation because new ideas are not being supported. However, we have also seen an increase in industry-sponsored work. Some consortiums have formed between big pharmaceutical companies and larger universities to spawn research and innovation.
GSN: In this “alternative facts” era, how can physicians best communicate important health information to patients?
Dr. Freischlag: First, it’s important to have those difficult conversations with patients and to make sure patients have the best information available so they can dictate their own care. The earlier you have that conversation with patients about their options, and the potential risks and rewards of different treatments, the better. Physicians and family members may be surprised at what the patient wants.
It’s also important to make communication easy. For instance, my doctor communicates with me online. She will email me the results of any tests and procedures, and I can look up all my test results. The information is protected, and I don’t have to wait to get a phone call.
Dr. Maa: Clear communication remains the key to good patient outcomes. In addition to face-to-face communication and telephone conversations, contact with patients can be achieved through vetted web-based protocols and guidelines, and even novel mechanisms like physician blogs. Honestly discussing the pros and cons of traditional therapies, novel innovations and experimental treatments will help patients better understand the overwhelming amount of information about their care available on the internet and in the media.
Dr. O’Shea: First, physicians need to be informed themselves before they attempt to help their patients. Second, during these conversations, it’s important for physicians to remove their personal agenda or bias when helping patients understand their options and make good health care decisions.
Dr. Karpeh: Patients have always come in with questions regarding things they have read. As a surgical oncologist, I am used to patients sharing things that they have read concerning alternative forms of care for their cancers. Much of that information is more accessible now because of the internet, but the bottom line is that I haven’t seen a movement toward alternative forms of treatments and away from more mainstream care now, compared with in the past. I think what we see in politics has not necessarily drifted into medicine.
GSN: How can we provide care for undocumented immigrants, who represent a notable percentage of the uninsured in 2017?
Dr. O’Shea: From a physician point of view, the oath we take is to provide health care to patients who need it. In terms of providing care, political issues should not get in between the doctor–patient relationship and the profession of medicine. As policymakers deal with these complex issues, physicians should actively engage in finding local solutions that address the health care needs of their community.
Dr. Maa: This is a very difficult question, and will require our country to address immigration reform, emergency services, charity care and international relationships more carefully. Studying how other nations handle the care of undocumented immigrants may prove helpful to the United States.
Dr. Karpeh: Providing care for undocumented immigrants is an issue, particularly in areas with a greater population of immigrants. Undocumented immigrants get injured, like any other person, and I’m not going to turn someone who needs care away from the emergency room. Unfortunately, there is no broad-base solution. There are some free clinics where physicians can volunteer their time to care for undocumented people. These free clinics provide the most structured forms of care in these situations. But every hospital has its own policy, and how a physician handles a situation may depend on the specific case.
Here’s an example of an individualized solution to a situation. When I first came to Hackensack, a resident from Korea had attempted suicide. The student had been in the hospital for over a year due to complications from his injuries. His health care was not covered. The only way we got him long-term care—care for his depression after he was stable, from a physical standpoint—was to fly him back to Korea, under a direct transfer to another hospital.
GSN: How can we promote price transparency in medical care?
Dr. O’Shea: People have been trying to do this for a long time, and it’s very elusive. Price transparency is a crucial piece of the value puzzle. If you think of value as quality divided by cost and you don’t have a good way to know what things cost, you will have a tough time figuring out value. More than half of U.S. states have passed legislation establishing price transparency websites or mandating that health plans, hospitals or physicians make price information available to patients. Employers have also contracted with companies to provide their employees with price transparency tools. However, there is little evidence so far that these tools have had an effect on health care spending. We need to do more work in this area.
Dr. Maa: A better understanding of the 1) true costs and 2) pricing of medical care is essential. Perhaps utilizing the power of the internet to share hospital charges and bills across the country will help to enlighten the conversation. Legislative efforts to require hospitals and insurers to post/disclose prices/bills have had only limited success. Perhaps the business sector will be able to introduce a disruptive innovation to help promote price transparency. Another challenge is the variable pricing for the same procedure across different insurance plans and payors. A deeper understanding of these prices will be of benefit to health reform efforts.
Dr. Freischlag: The cost of medical care is very confusing. The [University of California] system has looked at our revenue cycle and purchasing as a group, and we’ve found that different health plans can pay different things for the same procedure in the same state. As a result, we’ve worked to make these prices more uniform. [Dr. Freischlag previously worked at the University of California, Davis.]
Dr. Karpeh: Our system is complex, and we have a long way to go to improve price transparency. Part of the problem is the incredible price variability. Each insurance company has a different price list. Even physicians who work under the same insurance provider may receive different amounts for a procedure. Dr. X could be receiving $5,000 to perform an operation that Dr. Y receives only $3,500 to perform. I can’t even tell you what a hospital charges a patient for an operation I perform. A recent bill proposed in the New Jersey legislature would require physicians to disclose whether they were in a patient’s insurance plan before caring for them. If not, the physician would need to transfer care to a doctor in the patient’s plan. That’s about as close as we’ve gotten to price transparency for patients.
GSN: How do we move tort reform forward?
Dr. Maa: The health care system is a mirror for what needs to be reformed in our business sector, political systems, legal systems and societal expectations. The ACA provided for only minimal pilot programs in medical liability reform that were only funded to a limited degree. A number of proposals—such as health courts, safe harbors, no fault and other reforms—have been proposed elsewhere, and should be explored further. A key is to expedite the legal processes, and to ensure that those patients who have been harmed are properly compensated, but also that the court systems are not burdened by lawsuits without merit.
Dr. O’Shea: Although the current U.S. medical liability system, based on tort law, drives up health care costs by incentivizing defensive medicine and deters doctors from practicing in high-risk specialties and states with an unfavorable environment, malpractice reform is not high on the federal radar right now. For one thing, there has not been a “malpractice crisis” in over a decade. We’ve seen a number of efforts to provide a federal fix of the current system, all of which have been unsuccessful and have faced political challenges from both parties. Most of the innovative approaches to medical liability reform are currently happening at the state level. For example, nontraditional approaches, such as communication-and-resolution programs, pre-suit notification and apology laws, safe harbor legislation, judge-directed negotiation and administrative compensation systems, are currently being tested and show promise in addressing this issue.
Dr. Karpeh: Tort reform is necessary. The reforms will come down to each individual state. In New York and New Jersey, for instance, there is no movement to entertain tort reform. I think that the public trust is affected when doctors are not transparent about what happens in the hospital. When there is a reluctance to share information, everyone loses. If physicians and hospitals are afraid of being sued, they are less likely to be transparent and more likely to practice protective medicine, which is a component of increased health care costs and hurts health care in the long term. In moving tort reform forward, we have an opportunity to learn from past mistakes.
GSN: How can physicians and medical practices deal with the threat of physician shortages?
Dr. Freischlag: We need to use people to the height of their education and training. Patients don’t always need to see a doctor; nurse practitioners and other health professionals can take on a lot of responsibilities.
Incorporating telehealth into care is also key. For instance, at some ICUs, the doctor is in a remote area, overseeing 60 beds at multiple sites. This electronic ICU system can allow doctors to cover many more patients and provide cover at night. Telehealth can also help expedite diagnoses and allow doctors to determine whether patients in rural areas need to travel many hours to receive care at a big hospital.
We should place greater importance on providing preventive care: teaching patients to eat right and exercise, and compensating health care professionals for providing that care. In other words, we can’t only rely on old-fashioned forms of caring for patients. It’s increasingly important that we care for patients in new ways and pay health care professionals to do so.
Dr. Karpeh: We need a multipronged approach. Here in New Jersey, we’re opening a new medical school. One of the main impetuses behind this decision was to increase the number of physicians in the state and to start tackling the challenge of evenly distributing medical care across the country. Another important approach is to try to make medicine more attractive to high school and college students.
Dr. O’Shea: Although mid-level providers, such as nurse practitioners and physician assistants, can help alleviate some of the workforce stress, the important issue right now is graduate medical education. Although U.S. medical schools are on target to reach a nearly 30% increase in enrollment by 2019, there is currently a bottleneck in residency training because the number of federally funded positions has been capped at 1996 levels. To deal with the physician shortage, we need to reform the graduate medical education system, not just in terms of increasing the number of residency slots but also in terms of identifying the gaps in patient care by specialty and geography, and filling those gaps. This will likely require fundamentally rethinking the financing and oversight of graduate medical education in order to meet the broader health care needs of the nation rather than the narrow needs of the training institutions.
Dr. Maa: The medical profession will need to address physician workforce shortages across the country, which is most acute in rural areas. The need for greater regionalization of care, the use of telemedicine, and providing incentives to relocate where patient needs are the greatest merit further exploration.
The expanded use and standardization of locum tenens, the creation of a national medical health corps for loan repayment (similar to the Peace Corps), and improving physician resilience will also be key.
Fundamentally, our nation also needs to address medical student and resident loan indebtedness. With our future trainees accumulating very large amounts of student loan debt, the challenges with primary care shortages will continue. In the health reform debate, a call for either a single-payor system or universal health care is often made. What is missing from the debate is the recognition that in many other nations with those alternate systems of financing health care, that medical training is provided at almost no cost to the students. College and medical students in those nations do not accumulate massive amounts of loan debt, which greatly affects their American medical student choices after finishing school. A larger perspective on reforming undergraduate and graduate medical education as well as the other market forces, which impinge on health care, are necessary.