Enacted in March of 2010, the Affordable Care Act (ACA) aimed to provide Americans with better health security through comprehensive health insurance reforms.1 Since then, the ACA has helped to significantly reduce the number of uninsured Americans.2,3
While it is true that more Americans than ever now have health insurance, providers and other health care professionals have still pointed to a number of other issues impeding their ability to deliver the highest quality care for their patients. These include reported failings of payers to cover patients on clinical trials despite the Public Health Service Act, which was enacted as part of the ACA in January 2014;4 the sudden ubiquity of high-deductible health care plans, which are associated with a trend of decreased use of care services;5 avoidable drug waste related to container sizes, which reportedly leads to over $1 billion lost annually;6 and concerns regarding over-testing, which is suspected to be needlessly driving up health care expenditures.7 Together, these issues demonstrate that health care in the United States has a long way to go in order to become more efficient and provide better value for patients.
One organization leading the way in identifying methods for improving health care is the Right Care Alliance. Formed in 2012 under the auspices of the Lown Institute, Right Care Alliance is a partnership between clinicians and members of the public who seek to reform the current health care system to one that puts patients first while also being affordable, effective, rational, personal, and just. One of the primary means through which Right Care Alliance is working towards this goal is the formation of council groups, in which health care professionals, religious and community groups, as well as the public, gather to discuss topical issues in health care in order to derive more effective solutions. Current councils include specific topics such as nursing, pediatrics, and science and evidence.
To discuss some of the issues facing the American health care system as well as what Right Care Alliance is trying to do to fix them, the Journal of Clinical Pathways spoke with Vikas Saini, MD, President of the Lown Institute and one of the founders of Right Care Alliance. Dr Saini is a board-certified cardiologist and has been a long-time advocate for social reform in the health care industry.
Can you speak briefly to the mission and purpose of the Right Care Alliance and why you feel it is so important in today’s health care setting?
Our view is that the American health care system has a lot of dysfunction that is betraying central, core humanitarian values and that we need a broad-based effort in order to fix the dysfunction. This is partly because so much of health care has become money-minded and oriented to the business side. Because of that, clinicians are feeling enormous pressure to see more patients in less time. There is a quick impulse to use technology, and there is less time available to really listen to patients. And the consequences of this system are really over-treatment and under-treatment of different patients. Some of it is about a lack of evidence or poor evidence, but not all of it; there are other factors. So, because of that, we have to think systemically about it. We decided to take this initiative and reach out to clinicians to see if people were interested in gathering together and working together in order to start a social movement–style approach to changing care.
That’s our goal. We think we can get to a health care system that is truly universal, meaning everybody is in and nobody is out; that is affordable; and that is not just a privilege. Prevention will be an important part of that new system, as will a reinvented primary care. There are a lot of upstream factors, the consequences of which many of us in medicine have begun to see. And we think that there’s room for health care professionals to begin to draw the public’s attention to the fact that health and health care are not the same thing and how we get to health requires a lot more than just going to the doctor.
There are many other aspects. Transparency surrounding price and cost are important, and there needs to be more shared decision-making between patients and physicians. Science and evidence also really need to be improved, deepened, and extended in many ways, and how we use that information should be free of distortion or bias. So, that’s broadly our vision; at the end of the day, we think overuse and underuse are the entry points to a lot of this dysfunction. There’s a lot of waste in the system as well as resources that could be better deployed, but the mechanisms for sorting them out are insufficient. And all this leaves room for an organization like Right Care Alliance to take a public stand to restore some balance and revitalize the trust and ethics of health care.
What we’re doing is organizing clinical communities to create space that will allow health care professionals to share their understanding with each other, and with the public, and begin to tackle specific problems within the industry. The councils that we’ve formed have decided that the important next step will be to write a draft of principles to frame health care and practice improvement. Not guidelines, because a lot of different organizations are writing practice guidelines—which is one of the problems—but rather guiding principles for communities and institutions to improve how they deliver care to patients. What we’re talking about is not so much the technical details of what you should do in a given clinical scenario but rather the core values that should be part of the conversation. We’re not trying to create an encyclopedia for right care of every disease.
So, our role is to make a framework for people who see some of these problems to join with each other and begin transparent discussions about how we get to a health care system that is safe and really works for people. As we work, there will certainly be more specificity. At some point, there will emerge a consensus around specific areas, so we suggest that people stay tuned.
What can physicians, providers, or patients do on an individual level to help promote better efficiency in health care?
One of the really simple things we encourage doctors to do is to remind themselves to ask what they are going to do with the results of a test. Will knowing that information change how you treat the patient? Or are you treating yourself?
The other thing is to genuinely give patients options. When we’re fast-paced and hurried, doctors tend to make decisions for the patient. Often, that is perfectly reasonable, but the default needs to be something like: “Here’s the situation. To the best of our knowledge, it’s probably best to do ‘x,’ but if you want an alternative approach, we can try and work that out.” It is about offering people more options. In most of what we do, the evidence we use is very thin, so options are very important.
There is plenty of controversy around practices and treatments, so if you want to practice in a more informed way, you have to be willing to invest time into it. And if you do that, you’ll find that it is not as cut and dry as the headlines in the throwaway journals or even the headlines and graphs in peer-reviewed papers. I’m sorry to say it, but there really is a lot of slippage from the raw evidence to the data that gets presented in a paper, so it requires all of us to have a healthy skepticism.
Right Care suggests that clinical decisions be made without any fiscal considerations, but how would you suggest practitioners respond to patients whose greatest concerns are cost?
I would say that what is clinically appropriate is appropriate, regardless of cost. I’m old-school that way, and I think many clinicians would agree, but we also have to be realists in the sense that we know people face financial pressures due to their care, especially in the era of high copays and deductibles, which are a huge problem. So, in spite of some of the gains of the Affordable Care Act—and there are some—there’s also this huge element of under-insured people. So, the cost side matters to patients. You can’t ignore that; it should be something that is discussed with patients. What I mean is, our core—our starting point—ought to be based on what is most appropriate for the patient given their medical situation and their own preferences. What the right decision is and what they want should not be distorted by their ability to pay. That is a problem in our system and one that we, as physicians, have to recognize. And, therefore, we must admit that, when that clashes with the reality our patients face, we have a social responsibility that doesn’t stop at the clinic’s door.
The right care is really the right care, and we ought not to have financial matters distorting decision-making. Maybe that’s a subtle distinction, but there is a distinction between what is the right care and what is the right care after financial considerations or ability to pay. On the other hand, the patient’s situation and your responsibility to the patient of course have to include the notion that patients’ financial means are a part of his or her life. You can’t bankrupt the patient, and you’re dreaming if you think you can just write a script and tell him or her to go fill the medication. Because we know from a lot of studies that if patients can’t afford something, they just won’t take it. So that is a reality of our system.
Do you think clinical pathways can help reduce unnecessary costs?
Well, in general, it’s like so much of medicine: it’s a great idea in theory. The question is, how does it measure up in practice? In theory we know that there is huge variance in how doctors practice. Much of that variance is hard to justify on the basis of anything—whether it be evidence or underlying methodology. So, it’s a reasonable target to be trying to reduce variance and narrow the degree to which people do different things. And that’s sort of what guidelines and pathways are all about.
But in practice, the core question becomes, what is the evidence and data supporting those guidelines? Because billions of dollars are at stake. The pressure and influencers that come to bear on how we look at evidence and data and which evidence is reasonable is highly contested. So, I think the question of how we write those pathways and how we ensure that they’re faithful to what we really know are most important. They also shouldn’t over-promise or overly narrow the ability of practitioners to customize or personalize the care for their patients. We just have to figure out how to do that.
Pathways provide physicians the opportunity to make an informed decision, which I think is really great. The problems people often cite are that these types of tools can be coercive or reduce physician autonomy; they need to be crafted as nudges instead. It is the extent to which these pathways are designed in a way that doesn’t allow for considerations unique to the patients’ situation that is most problematic and needs to be addressed. But, at the end of the day, physicians are also responsible for ensuring that conscious or unconscious bias doesn’t taint treatment decisions, particularly when it involves care that is a revenue driver for your practice but doesn’t add much or do much for the patient. For that, we can’t rely merely on our good intentions; we need a new system that makes decision-making in the best interests of the patient, independent of financial considerations.
What kind of feedback have you gotten about the work Right Care Alliance is doing?
We are getting quite a response. There are clinicians from all over the country who are really feeling like something is seriously wrong. Although they find it hard to articulate what that something is, it generally boils down to the fact that there is too much getting in the way of us doing our jobs, which is to take care of patients. And a lot of what is getting in the way is the business end of health care. So, we’re hearing that feedback, understanding it, and building a response.
References
1. Affordable Care Act. Medicaid Web site. https://bit.ly/1VEHKth. Accessed April 8, 2016.
2. Smith JC, Medalia C. Health insurance coverage in the United States: 2014. https://1.usa.gov/1qAMk0j. United States Census Bureau: current population reports. Published September, 2015. Accessed April 8, 2016.
3. Radnofsky L. Percentage of Uninsured in U.S. Dropped in First Year of Obama’s Health-Care Plan. The Wall Street Journal. https://on.wsj.com/1SF4F2F. Published September 16, 2015. Accessed April 8, 2016.
4. Johnson K. Payers Still Denying Coverage Despite Clinical Trial Mandate. OncLive Web site. https://bit.ly/1Skehzg. Published March 29, 2016. Accessed April 8, 2016.
5. Sinaiko AD, Mehrotra A, Sood N. Cost-sharing obligations, high-deductible health plan growth, and shopping for health care: Enrollees with skin in the game. JAMA Intern Med. 2016;176(3):395-7.
6. Bach PB, Conti RM, Muller RJ, Schnorr GC, Saltz LB. Overspending driven by oversized single dose vials of cancer drugs. BMJ. 2016. doi: 10.1136/bmj.i788.
7. Wolfson D. Choosing Wisely: Addressing the overuse of medical tests and procedures. Journal of Clinical Pathways. 2016;2(3):21-23.
