TMC PULSE

t m c » p u l s e | a p r i l 2 0 1 7 4 A ny national health care overhaul must embrace the basic needs of the individuals it aims to serve and acknowledge the particular challenges for the professionals and institutions providing the care. Under President Trump, health care in America was poised for change. But the bill to repeal Obamacare—the American Health Care Act (AHCA), sometimes called Trumpcare— never even made it to a vote. House Republicans pulled the bill in late March because they knew it wouldn't pass. So, for now, Obamacare stays. As we pause in this race to reinvent the way Americans receive care, let's take a moment to outline the baseline tenets of any sustainable health plan that intends to serve the common good. People deserve access to afford- able, adequate health care. When we talk about "access" to health care, we mean that a patient should be able to see the right medical practitioner, at the right time and in the right place. That place may be via email or video; it is certainly not an emergency room, unless the patient is experiencing a true health emergency. "Affordable" refers to the total out-of-pocket cost for which a patient is responsible—the premium plus the deductible. Ideally, these costs should be no more than five to 10 percent of a patient's income: for lower incomes, it should be five percent. For example, if a patient earns $20,000 a year, then, he or she should expect $1,000 in out-of- pocket expenses. This is not the case with Obamacare, which costs $6,449 for someone who makes $20,000. That's too much. "Adequate" speaks to a basic level of care that everyone needs. This is tough to define, but going forward, legislators who want to rework Obamacare will have to get specific. Providers should receive pay based on the quality of care. Physicians, nurses and other medical workers should be paid a base salary for their level of expertise, along with a bonus that corresponds to the quality of care they deliver. The fee-for-service model—in which doctors bill based on the procedures used to treat a patient—should be a thing of the past, as it encourages unnecessary tests and procedures. Currently, providers spend just 55 percent of their time caring directly for patients, while the rest of the time is consumed by administrative tasks. We need well-functioning electronic health records that streamline care instead of adding time and hassles. Finally, health systems should receive payment in a way that encourages innovation and rewards value. The American health care system should improve cost and quality, and increase life expectancy in patients. Cost and quality must be considered together. We don't want to reduce cost only to have quality suffer. According to Donald Berwick, past administrator of the Centers for Medicare and Medicaid Services, we waste one-third of our health care dollars—about $1 trillion per year—on overtreatment, failures of care coordination, failures in execution of care processes, administrative complex- ities, pricing failures, fraud and abuse. If we could just save 15 percent of this waste, we could pay for the uninsured. Here are three ideas: pay physicians a salary, instead of allowing them to bill per procedure, potentially saving more than $180 billion per year, according to Berwick; fund a streamlined electronic health records system, which could generate $81 billion in eventual yearly savings, according to Rand, a global nonprofit think tank; and attack chronic disease, which would help reduce emer- gency room visits, readmissions and unnecessary admissions to facilities. With the AHCA off the table, at least for the present, Americans are left with Obamacare. Now what? Obamacare expanded Medicaid to the poor between ages 19 and 64. Many legislators did not realize that about two-thirds of the people who are uninsured actually work, but could not afford the premiums and the deduct- ibles, now totaling about $6,500 for a single person. Medicaid expansion and the pre- mium subsidies totaled about $190 bil- lion per year—and with current prices, amazingly, that wasn't enough. Really, the only way to deal with this problem is to make health care and health insurance less expensive. We could start by paying doctors salaries and giving bonuses for quality of care, eliminating the perverse practice of paying doctors for every procedure they perform. The Mayo Clinic, the Cleveland Clinic, Kaiser Permanente and other great health systems pay their physicians salaries. All should. This could save from $190 billion to $300 billion per year. The next big health care overhaul— or the insurance industry itself—should create catastrophic plans that can be bought by anyone. The design of the plans is not trivial: The plans would cover accidents, of course, but when would they start covering heart failure? The challenge is that these plans would need to be affordable, which means a low premium plus a low deductible. The mistake of Obamacare is that less expensive plans typically have higher deductibles. The only way insurers can stay afloat is if healthy people buy their plans. We know from our Texas Medical Center-Nielsen survey that 96 percent of people across five states said they would buy insurance if it was affordable. Let's not just stare at the future, let's do something. Let's put bipartisan groups together to consider these and other ways to reduce cost. The health of the nation depends on it. Arthur "Tim" Garson Jr., M.D., M.P.H., is director of the Texas Medical Center's Health Policy Institute. Parts of this essay have been published previously in The Hill. The Future of Health Care The American Health Care Act failed. So what sort of plan do Americans need? B y A r t h u r G a r s o n J r . , M . D . , M . P . H . House Speaker Paul Ryan of Wisconsin at a news conference following a Republican party conference at the Capitol on March 15, 2017. Credit: AP Photo/Andrew Harnik

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