In his speech to the AcademyHealth National Health Policy Conference, Rep. Rob Wittman (R, Va.) spent the first half of his time recommending policies that empower patients and providers -- "not payers"-- to actively engage on issues related to cost, value, and efficient use of finite resources.
I was surprised to hear Wittman -- an ardent legislative opponent of the ACA -- push these issues to such a prominent place in his talk. Granted this was a policy-oriented audience and it is not unusual
Photo: Hoag Levins
Zachary Meisel, MD, MPH, MSc, is an emergency physician and Assistant Professor of Emergency Medicine at the University of Pennsylvania's Perelman School of Medicine, and a Senior Fellow at Penn's Leonard Davis Institute of Health Economics (LDI).
for an elected official to invoke fiscal responsibility around any policy initiatives. Nevertheless, politicians have been notoriously reluctant to conflate the issues of health care utilization and cost.
'Rationing' and 'death panels' This reticence to openly address cost and value has been a matter of political expediency. Many previous attempts have devolved into accusations of "rationing" and "death panels." Moreover, patients and consumers alike have been known to explicitly reject terms and ideas such as "value", and even "evidence-based decisions" when it comes to health.
But perhaps Wittman, who has degrees in public policy and public health and worked for twenty years in the Virginia Health Department, is sensing a sea change. He latched on to an issue that seems to be gaining public traction as the result of the media's expanded focus on confusing and ridiculously high hospital bills.
'Where the wheels come off' Wittman invoked personal (but relatable) anecdotes that included receiving multiple statements and "sort-of-bills" from hospitals, insurance companies, and creditors -- none of which actually explained the true out-of-pocket costs. "This," he said, "is where the wheels come off."
So how do we engage a public that might be increasingly interested in thinking about cost and value?
Given that understanding value requires consumers to understand both real costs and real quality, the current landscape of confusing hospital-based "charge masters", sensational news stories that highlight crazy hospital bills, and local efforts to get hospitals and doctors to publicly report their prices doesn't seem to be helping people who care about true cost and value in health.
While it is laudable for Congressman Wittman to invoke cost, value and transparency in his talk,
Photo: Hoag Levins
Rob Wittman is a Republican Congressman from Virginia who wants patients to have more access to health care cost and value data.
he offered no specific policies or even ideas on how to link patients with the real data they need to make rational or patient-centered choices. Perhaps he didn't have time. So, here are a few ideas that seem to be missing from the increasing (but often vacant) types of calls for "transparency".
Crowdsource pricing info First, let's end-around the hospitals and providers in the effort to find (and sort) the out-of-pocket cost data that consumers can use. Why should we rely on what hospitals charge to figure out what consumers pay at the end of the day? Consumer-driven innovations, such as crowdsourcing bills, could actually be a way to bring real patient cost data (what they actually paid) to light.
Second, let's invest in patient centered outcomes research that includes cost and value. Much of the federal research support infrastructure (including grants from PCORI, the Patient Centered Outcomes Research Institute) is prohibited by statute from measuring cost or cost effectiveness as an outcome. If patients' lives are being profoundly affected by out of pocket costs for healthcare services, doesn't the research that helps them weigh the costs and benefits of different types of care qualify as patient centered? Couldn't results from these types of studies actually be used to improve transparency around health care costs?
Reframe the conversation Last, let's reframe the conversation around value for consumers and providers in a way that has meaning. It's really hard to convince a patient or a doctor in the heat of the clinical encounter that skipping a test (or a trip to the ER) will be "good" for them. But it often is. We just have to find the ways to explain it, through good stories or meaningful frames, in a way that brings the concept to life. The "Choosing Wisely" campaign from the American Board of Internal Medicine has been shifting the conversation from "reducing costs by reducing use" to the more noble and liberty-oriented frame of "making better choices."
Empowering patients to think about cost and value shouldn't be taboo. Doubtless, public sentiment will back policymakers, from either side of the aisle, who can help patients and consumers in this respect.
Better data combined with better stories can create a win-win scenario for politicians, providers, payers and patients alike.
