Page 25 - HME Business, November/December 2019

• 2014 Competitive Bidding Program: Nationwide Expansion – $4.4 billion reduction over five years in select HME nationwide started January 2016.
• The Patient Protection & Affordable Care Act of 2010 – Reforms private insurance, especially for individuals and small-group purchasers. Significant expansion of Medicaid. Fundamentally change how health care is provided; HRRP, ACO, VBP, etc.
Common themes in health policy:
• Expand and improve access to healthcare services for all stakeholders
• Fix/improve Medicaid, Medicare A, B, C & D, SCHIP
• Create more standards, regulations and controls around the provision of healthcare services • Drive care models in specific directions, too
often focused on cost reduction
• Lower the cost of care for the payer
• Prevent fraud, abuse and over-utilization • Lower the cost of care for the payer
• Prevent fraud, abuse and over-utilization • Lower the cost of care, period
Silver Bullets or Blanks?
Most initiatives demonstrate evidence of being both a silver bullet and a blank. Healthcare in the U.S. is extremely complex; there are so many variables that influence and impact every element of the system. This is a recipe for a series of unintended consequences, which there are so many from the aforementioned laws and regulations it would take a much longer article, more likely a book to review. A few that will stimulate hours of discussion and debate include any government funded entitlement program, diagnosis related groups (DRG), managed care, competitive bidding, readmission penalties, ACOs, and the major disconnect and competing incentives between healthcare organizations and stakeholders.
Why don’t these many complex initiatives yield the outcomes initially hypothesized? There is no simple answer, but it is clearly influenced by two impor- tant variables—medicine and human behavior. Medicine is not a pure science, it is a mix of art and applied science. Even with the continued growth of evidence-based medicine and standardized care, there are always outliers. Humans are complex organisms that don’t always respond to treatment as intended. More importantly, humans are human and don’t always follow the care plan or even gener- ally healthy and good behaviors. Add these together and you get unintended outcomes. That said, I would argue human behavior has a disproportionate impact on outcome for most healthcare issues.
Healthcare is also a business, one with large, complicated and expensive overhead. Lowering reim- bursement, along with adding excessive regulatory oversite often triggers operational/business responses that may not be ideal for healthcare consumers and other stakeholders, as many organizations are forced to look for new ways to replace the lost revenue and reduce the uncovered operating costs.
Competing, conflicting and often perverse
incentives between health systems and providers, which are often the result of policy and regulation, is a major complicating factor and adds nothing but complexity and cost to the already overly complex and costly system. Although the ACO is a model of care intended to align various provider functions with common goals and incentives, this one is still in a test tube, with early data showing mixed results.
What will work? Despite the push for a single- payer/socialized model, the evidence from countries with similar models isn’t great. Most of the mature, socialized models, such as those in western Europe, are struggling financially. While they often outper- form the U.S. in general, primary care services, these systems are often overburdened, under- funded and struggling with providing complex care and services, especially those considered elective.
There are no silver bullets, but there are some common sense ideas:
• Aligning incentives across the healthcare continuum. Reduce the competing and conflicting incentives that drive activities and behavior at each level of the system.
• Force transparency in the cost, quality and payment process. There is information “asymmetry” in healthcare; the seller knows more about the quality of the product/service than the buyer. This often results in the buyer over paying and potentially, over- buying. This is exaggerated in healthcare, when the
bill comes long after the service and is partially or completely paid by a third party.
• Free markets drive healthy competition, drive up quality and rationalize cost. Allow national competition for health insurance. The current system is an oligopoly that limits competition to within a state.
• Develop more focus and incentives for preven- tive medicine & wellness. Change the paradigm from disease management and acute interventions to focus on personal health accountability, diet, exercise, and preventive medical care. Prioritize wellness over sickness.
• Shift more responsibility and accountability to the individual. Educate and empower consumers to make informed, intelligent decisions. We should be “entitled” to make educated, informed decisions about our healthcare.
There are no easy answers. We must think differ- ently about how we provide healthcare and stop looking for silver bullet solutions. n
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Management Solutions | Technology | Products
hme-business.com | November/December 2019 | HMEBusiness 9
Joseph Lewarski is the Senior Vice President of Global Business — Clinical Care at HME manufacturer Drive DeVilbiss Healthcare (www.drivemedical.com). He has worked
in respiratory care for more than 35 years, including with HME providers, the U.S. Navy and major equipment manufacturers.