In America, we’ve come to expect the best of everything. However, when it comes to health care, we pay more in this country than anywhere else in the world — yet the United States falls behind other countries on measures of health outcomes. Millions of Americans do not have or cannot afford the health care they need. We need to rethink how we pay for health care and develop differentiated payment models across the spectrum of primary, intermediate and complex care.
The Affordable Care Act encourages health care providers to work together collaboratively and accept collective accountability for the cost and quality of care delivered to the vast majority of patients. This moves patient-centered health care in the right direction, but much more needs to be done.
We must first recognize that there is a spectrum of care. During our lives as our health changes, each of us will use different aspects of the spectrum of care. For example, patients who experience a heart attack or require knee replacement will need intermediate care. A small percentage of patients, perhaps 1 in 1,000 each year, have conditions that are difficult to diagnose and treat and need complex care.
Then, we must make tools readily accessible to providers that will allow them to find better, more affordable ways to care for patients. Providers need information on outcomes for care across the spectrum and total cost of care over time. Without it, providers will never be able to embrace the elusive goal of value — high quality care at lower costs.
Mayo’s work with Optum, a subsidiary of United Health Group, is an important and promising step. We’re bringing together vast reservoirs of clinical and claims data that’s stripped of all personal identifying information to protect patient privacy to truly assess some basic questions — when it comes to health care, what works, how much did it cost and who’s doing best? As results are known and broadly shared, patients, providers and payers can seek and reward those who are providing the highest value.
The potential for this relationship will be made more remarkable when others join the alliance — academic medical centers, research universities, pharmaceutical and device companies, policymakers and other payers.
Government needs to recognize, but more importantly reward, excellence across the spectrum of care — primary, intermediate and complex — and do its part to create a competitive marketplace where data drives innovation and better care at lower cost.
Payment changes should include incentives and rewards for the proper management of complex cases. Patients, providers and taxpayers alike get into trouble when patients “churn” in the wrong part of the spectrum of care, when health professionals fail to coordinate care and smooth transitions across the spectrum. The irony of our current system is that the financial return of mismanagement is far greater than when patients are correctly and efficiently diagnosed and their treatment is properly managed.
Congress must also address the Sustainable Growth Rate, a complex formula that determines Medicare physician payments. The SGR is broken. It has not been effective at controlling the volume of physician services, largely because it does not distinguish between those doctors who provide high quality care to beneficiaries and those who provide unnecessary services. Physicians who provide the most efficient care are penalized under Medicare’s current payment system while physicians who order more tests or perform more procedures are paid more.
When Congress takes action, the solution should include repeal of the SGR, a plan to stabilize payments during a transition period and establishment of new payment models that tie reimbursement to patient-centered care and quality outcomes. These payment models should allow providers to choose the payment option that best fits their health care practices. Americans deserve a payment system that will actually work with the way that our country uses health care, one that recognizes the different types of care and rewards quality and value of each.
We are at a turning point in health care in America. The answers to the challenges we face will not be simple, but if we align how we pay for care with how we diagnose and treat patients, we can reach our goal of high-value health care for every patient.
John H. Noseworthy, M.D., is president and CEO of Mayo Clinic and a neurologist.
Rep. Elijah Cummings, D-Md., right, hugs Harold Schaitberger, General President of the International Association of Fire Fighters, after the Congressman spoke at the IAFF's Legislative Conference General Session at the Hyatt Regency on Capitol Hill, March 9, 2015. The day featured addresses by members of Congress and Vice President Joe Biden.