The healthcare debate we’re not having

healthcare patient
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healthcare patient

The headlines from Capitol Hill give the impression that Congress is debating the future of U.S. healthcare. That’s somewhat misleading. The debate is about health insurance, not healthcare.

It is an important distinction. Insurance is a ticket to enter the healthcare system. Healthcare is what the system delivers. To be sure, if Congress rolls back insurance coverage, it will prevent millions of Americans from gaining timely access to healthcare. That is a bad outcome in itself and worthy of the attention it’s getting.

{mosads}Nonetheless, a real debate over healthcare would begin with an accurate diagnosis of our ailing system. We have the world’s most expensive healthcare, and despite the superior quality of American providers, science and technology — our life expectancy and infant mortality rates are the middle of the pack among developed nations.


The cost, quality and patient experience of care varies widely among doctors and hospitals. Despite billions of dollars of investments in information technology, medical records still don’t follow patients across providers, and we lack the real-time data insights that fuel quality improvement in other industries. Finally, our healthcare system emphasizes treating people when they are sick — not keeping them well. 

Federal policy on its own cannot improve the sector’s leadership, culture, cost or quality. Those of us who provide care must step up and accept accountability for the results we deliver. But the federal government can help us chart a course toward more patient-focused, coordinated and cost-efficient care by giving us the right incentives, setting consistent rules and removing the roadblocks.

That’s why a new debate should begin with the topic that is currently missing from the headlines: payment.

We pay for most healthcare services today one by one, a system called “fee-for-service.” The more services a doctor or hospital delivers, the more they get paid. Sicker patients earn them (us) higher payments and drive each healthcare team member to concentrate on the services they alone deliver, not the patient as a whole person. As a result, we care for people in a fragmented, inefficient and costly fashion.

Conversely, if we were to pay providers based on the quality and cost of care they provide, they would more likely focus on keeping people well, managing patient illnesses and preventing costly interventions that send people to the hospital. This is known popularly as “value-based care.” It may be a poor choice of phrases, conjuring up K-mart’s blue-light special instead of Tiffany’s light blue box, but the point is the right one: payment should reward the value of services — not the volume. Value-based payment holds providers accountable for the quality of their care, and puts their payments at risk if they don’t deliver.

The federal government can play a decisive role in moving the ball forward. Medicare alone accounts for 20 percent of all healthcare spending. Under both Democratic and Republican administrations, Medicare has begun to embrace value-based payments.

But instead of accelerating this trend, the Trump administration has proposed slowing it down, albeit to avoid overwhelming small physician practices. If we stay on this course, it will penalize early adopters like Prevea Health and many of my fellow American Medical Group Association members, which have invested millions reengineering systems to provide value-based care. The administration should be helping lead the way, not putting on the brakes. 

We also lack timely access to Medicare and commercial payer claims data about the very patients we serve. Data is the lifeblood of quality improvement, and without it, we lack the feedback we need to improve patients’ health outcomes. Congress can fix this by requiring both federal and commercial payers to provide access to this data.

But data is also a double-edged sword. Currently, Prevea is required to submit data to numerous payers in different formats. And we are not alone shouldering this incredible burden on financial and workforce resources that could be spent on patient care.

One study reported in Health Affairs found that physicians in four common specialties spend, on average, 785 hours per physician and $15.4 billion annually dealing with the reporting of quality measures. Congress should require federal and commercial payers to standardize the data submission and reporting processes. 

In the depths of the Great Depression, FDR said, “The country demands bold, persistent experimentation. It is common sense to take a method and try it: If it fails, admit it frankly and try another. But above all, try something.”

Bold, persistent experimentation is what we, as healthcare leaders, need to be asking of Congress. We know the healthcare system we have isn’t serving our best interests. The debate we should be having in Washington and throughout our country is about creating a system that will.

Ashok Rai, M.D., is president and CEO of Prevea Health and the incoming chairman of American Medical Group Association, an Alexandria, Va.-based association representing multispecialty medical groups and integrated systems of care. 

The views expressed by contributors are their own and are not the views of The Hill.
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