AJMC®: Hiya, I am Matthew Gavidia. As we speak on the MJH Life Sciences’ Medical World Information, The American Journal of Managed Care® is happy to welcome Invoice Kramer, government director for Well being Coverage on the Pacific Enterprise Group on Well being (PBGH).
Nice to have you ever on, Invoice, are you able to simply introduce your self and inform us somewhat bit about your work?
Kramer: Hello Matthew, thanks very a lot for inviting me as a part of this dialogue as we speak. I am the chief director for Well being Coverage at PBGH, which is a consortium of enormous employers, a not-for-profit group that is dedicated to enhancing high quality, value, and fairness for well being care throughout the US.
AJMC®: To get us began as we speak, as 2020 noticed an increase in digital care and telehealth providers amid the pandemic, in addition to a larger concentrate on psychological well being and social determinants of well being, what targets or aims could have notable affect on employer motion in 2021? Will it’s extra of the identical?
Kramer: Properly, first coronavirus illness 2019 (COVID-19) has had an amazing affect, after all, on our whole well being care system. A kind of has been the acceleration of some lengthy overdue adjustments in well being care. An ideal instance of that is the speedy transition to telehealth and different kinds of digital care.
That is been lengthy overdue, the know-how has been obtainable, and now it is being put into place to the advantage of sufferers and physicians and hospitals. However there are different points that must be addressed going ahead, along with, after all, coping with the COVID-19 pandemic.
Prices proceed to be a major problem for employers and, after all, their staff and their households who obtain advantages by their employers. Prices are by the roof—they proceed to be an unlimited burden, not solely on companies, however additionally they crowd out wages. Excessive well being care prices have led to a flattening of wage development over the previous 20 years. We have to discover methods to include the price of well being care throughout the US with the intention to strengthen wage development, strengthen enterprise development in the US.
One of many different issues we have to do going ahead is to strengthen major care. Major care has been hit actually arduous in the course of the COVID-19 disaster, notably impartial major care practices that have been maybe financially susceptible, notably these impartial practices that relied quite a bit on fee-for-service (FFS) income.
Now, there have been some steps taken to shore that up, however that is nonetheless a really fragile a part of our well being care supply system. It is advisable discover methods to protect major care, however extra importantly, to strengthen it, make it extra resilient, as a result of it’s the basis of a top quality, inexpensive, accountable well being care system.
AJMC®: What significance will the transition to the Biden administration have for employers in 2021? And what would be the affect of the shift to a Democratic majority within the Senate?
Kramer: There are important alternatives to work with a Biden-Harris administration on well being care coverage. The number one precedence, after all, might be to take care of the COVID-19 pandemic. That is important for the well being of our nation and for our economic system, however past that, there are a variety of alternatives.
One is cost reform. Once more, that is one in all these lengthy overdue reforms that is been wanted for a very long time to maneuver us away from FFS cost, and towards extra value-based cost the place physicians, hospitals, and different clinicians are paid for the standard of care that they supply for enhancing the well being of their sufferers.
We consider we are able to work with the brand new administration to not solely develop, but additionally implement extra broadly these sorts of cost reforms. Together with that, there must be an emphasis on accountability. Accountability comes by guaranteeing that sufferers are getting the care they want and are getting the well being outcomes which are obligatory. To try this, we have to have good transparency, we have to have good efficiency measurement. Once more, employers are trying ahead to working with the administration on stronger efficiency measures and accountability tied to cost reforms.
Final, however not least, there must be a solution to include well being care prices extra broadly–not simply in Medicare, however all through the well being care system. One of many foremost causes for prime well being care prices has been excessive costs, not simply excessive utilization, and in lots of markets, these excessive costs are pushed by dominant well being care methods. We have to discover a solution to both restore competitors by stronger antitrust enforcement or prohibition on anti aggressive practices, but additionally to, the place obligatory, restrict the costs that may be charged by these dominant well being care suppliers.
AJMC®: Past on the federal stage, are there any state-level adjustments to well being care coverage that employers must be monitored?
Kramer: Sure, I believe there are numerous alternatives on the state stage. Once more, the states are additionally going to wish to make COVID-19 a primary precedence, however past that, there are numerous promising initiatives.
Many states have launched or are contemplating well being care value containment commissions. Massachussetts was one of many first, however California additionally has a proposal, Oregon has been growing one—many states have been doing this. Lots of them have really set targets and are monitoring well being care prices, trying on the underlying causes which were driving up costs, and setting targets to make sure that prices do not exceed a sure restrict.
As well as, to strengthen markets, some states have taken steps to strengthen antitrust enforcement, and California is a type of. An actual good instance of that is what was accomplished to take care of the issue of Sutter Health Care System in Northern California. As you in all probability know, there was an antitrust swimsuit launched, initially a category motion swimsuit led by a labor belief fund after which it was joined by the California Lawyer Basic. That swimsuit goes to be settled and formalized shortly, however it factors to each an issue, but additionally an answer. If we are able to strengthen antitrust enforcement and make markets work higher, we are able to convey these prices below management.
Lastly, different issues that states could be doing, and lots of are are already doing this, improvement of all-payer claims databases so now we have a clearer image of what the costs and prices are which are being charged, and likewise initiatives to shore up and strengthen major care infrastructure, in lots of instances, investing extra in major care. Once more, a very powerful basis for a patient-centered, resilient, and cost-effective well being care system.
AJMC®: To be taught extra, go to our web site at AJMC.com. I’m Matthew Gavidia, thanks for becoming a member of us!