Podcast episode transcript: Bringing the consumer’s voice to health care

With L. Gordon Moore, MD

Gordon Moore: Welcome to three 3M’s Inside Angle podcast. This is your host Gordon Moore. And with me today is Sophia Tripoli, she’s the director of Health Care Innovation at Families USA, where she leads Families USA’s work on value initiatives that focus on reorienting the health care system to deliver health and on forwarding consumer-focused policy agendas to improve health care delivery and payment systems. Sophia represents Families USA as co-chair of the public policy work group for the Health Care Transformation Task Force, and represents Families USA on the National Advisory Committee for the National Center for Complex Health and Social Needs. Welcome, Ms. Tripoli.

Sophia Tripoli: Thank you so much. Thanks for having me.

Gordon: Yeah. I’m excited. The work that Families USA and Consumers First is doing is fascinating to me, I want to get into that. But first, could you paint a picture of what is Families USA to those who may not know you?

Sophia: Sure. Families USA is a leading national, nonpartisan voice for health care consumers, and we are dedicated to achieving high-quality, affordable health care, and improved health for all. Our work is really driven by four pillars, health care value, health equity, health care coverage, and consumer experience. And we really view these four focus areas as the cornerstones to America’s health care system.

Gordon: Excellent. And I know that you guys are cited as being an important force behind the Affordable Care Act and therefore have had significant impact in bringing the consumers voice to health care, and so that’s part of what I find exciting. And you have convened a group called Consumers First. Tell me a little bit about that.

Sophia: Yeah. Absolutely. Consumers first launched in 2019, and it’s full title is, “Consumers First: The Alliance To Make The Health Care System Work For Everyone.” And it’s an alliance, a coalition that brings together interests from consumers, children, employers, labor, and primary care, all working together to change the fundamental economic incentives and design of the health care system. Our work is really focused on realigning the incentives and design of health care so that the system is actually going to deliver the health and high value care that all families across the country really deserve.

And part of this is really focused on what are the underlying fundamental, we often refer to them as distortions, but really drivers of high costs and low quality care in the health care system. And we set out, a couple of years ago, with an expert roundtable bringing together industry leaders and former administrators from across federal agencies and thought leaders from across the country, and we really pushed a hard on pulling back the curtains and identifying what drivers were. And with without too much surprise, we really coalesced around six areas, one of them around the high cost of prescription drugs, which is of course very timely for today as there’s a hearing going on in the house and labor committee right now on a bill that would address lowering health care costs.

The second one is around incentives within our payment systems, including Medicare, that might have higher weighted reimbursements towards specialty care instead of primary care, and how we value different services within the physician fee schedule and across the health care system and our payment systems. The third area is around the impact of industry consolidation on health care prices, which is a really big driver. Another area is around health care workforce, how is our graduate medical education system structured, and what kind of changes do we need to make to our health workforce system and reimbursement system to really build a health workforce that’s equipped to meet the needs of the 21st century.

The fifth area is around data sharing and price transparency, which is a huge area, and I imagine we’ll spend some time chatting about that today. And then the sixth area is around the tax exempt status for nonprofit institutions, and there with focuses on making sure that institutions that are claiming nonprofit status are actually making investments back into the communities they’re serving, into addressing the social determinants of health, into addressing community specific needs, rather than only building a new wing of their hospital and driving revenue through those new buildings, but there’s actually reinvestment happening back into the community.

Gordon: That is a fascinating list, and I’m really interested in all of those things. And what I’m thinking about is that the Consumers First has published in administrative agenda, “Policy Solutions to Strengthen the Infrastructure of the US Health Care Payment and Delivery.” I’m fascinated by that. How did that report come about?

Sophia: Yeah. Well, of course we knew, as we were coming into working through 2020, that it was an unprecedented time. Obviously 2020 an election year, possibility of a new administration coming in or an existing administration taking over another four years, and of course in the middle of a global pandemic. And so we knew there was a lot on the table for the American people in terms of the health care system. And what we also knew is that these underlying drivers of costs and poor quality and health care system persist regardless of what is happening, regardless of who is in office.

And what we saw during the COVID pandemic, and we continue to see, is really this amplification of all of these underlying fragmentations, all the fragmentations within the health care system that really have created a system where families, consumers, people can’t afford their health care, they’re getting dropped through the system, they’re not getting the coordinated services that they need, their health, our health is not improving. As you know, we spend more than any other OACD country on health care and yet we have some of the worst health indicators on key indicators like maternal mortality, infant mortality, we have the lowest life expectancy.

So we had this incredible moment where we were looking ahead and recognize that we needed to put forward some really bold ideas regardless of who’s going to be in office. And what’s really interesting about this agenda, and what’s interesting about Consumers First is that the issues we take on are really bipartisan issues. And there’s a lot of power behind that, especially in today’s climate. So that was the big picture thinking.

And as we moved into the end of the year and it became clear who the winner of the election was, and we came into the beginning of 2021, we really pushed forward with building out this administrative agenda and putting a blueprint in the hands of the Biden administration for them to be thinking about these different levers that we need to be pulling on to be driving value into the health care system for this year and for the future.

Gordon: Now, tell me some of those levers.

Sophia: Sure. So I think the first is really focused around, and I think one of the biggest ones is focused around this growing mammoth in the room, the big elephant in the room that nobody ever wants to talk about, which is consolidation in the health care system. It’s not new information, almost 20 years ago, Uwe Reinhardt wrote about it’s the prices stupid, and that’s why health care costs are so high in the United States it’s because of our prices. And then the last decade and a half from researchers from academic institutions across the country, from attorney generals in various different states, former Attorney General Martha Coakley in Massachusetts put out landmark studies that really correlated high prices to market consolidation particularly among hospital systems, both of hospitals horizontal integration, as well as vertical integration.

And one of the biggest levers we have in this space is getting to a place where we can regulate the markets. As markets become so consolidated, we know that prices are no longer competitive, there’s no longer this healthy competition that we believe so dearly in, in the United States health care system and in our economic beliefs. And so what we need is the government to step in and to help reset some of the ground rules, make the playing field level, allow institutions within the health care sector to actually compete based on cost and quality.

Gordon: Yeah. So I’m curious when you say, let’s let health care systems compete, but when I look around, I haven’t studied this deeply, but the impression I’m getting is that a lot of these health systems are almost monopolies in their geography. How does that lead to competition?

Sophia: Well, that’s exactly the problem is that we have monopolistic markets. And that’s where our health care prices are coming from, they’re not coming out of healthy market competition, they’re coming out of monopolistic health care markets, and so that’s exactly the problem. We need government intervention, we need congress to pass legislation, we need HHS to step in, the FTC to make some recommendations and others to step in and make some really strong policy changes to restore competition in us health care markets.

Gordon: All right. So let’s pivot to one of the other levers or other recommendations for policy change.

Sophia: Sure. One of the other areas that we talk about is around price and quality transparency. And this is really critical to be able to know what underlying health care prices even are to be able to see price and quality information together, whether you’re a policy maker, whether you’re a consumer, whether you’re a researcher, whether you’re an employer and trying to negotiate benefits for your employees. And so this is really about disclosing price and pairing it with quality information and allowing information to flow.

We’re in a situation now where you walk into any office across any health care service that you need and you don’t know what the price or the quality of that service is until you’ve received the care and gotten the bill. And so those are pretty perverse incentives, and so we want to flip that on its head and say, “Just like most other markets in the United States, you should be able to know what your cost is going to be to you as well as, is this going to be good quality, is this going to be bad quality.“ We used to make that assessment before you’re receiving care to make more informed decisions about care.

Gordon: So I like that idea, but I’m also daunted by the complexity of it. I remember when I was in the solo practice and doing my own fee schedule and billing that I had a different fee schedule—I set up—here’s my fee schedule, but then each health plan had their own rates. And they said, “Well, this is your rate, you sign the contract or you won’t get any of our members.” And I’m like, all right, I guess I signed it. And then each health plan could have multiple different purchasing arrangements with the employers, and they were all nuanced by their own version of how much co-pay, how much deductible. It was mind blowing just from my perspective, then people would ask me how much it’s going to cost me, it’s like, I have no idea. Here’s my fee schedule, but what you’re going to pay, really, is beyond me. How do we deal with that?

Sophia: Yeah. It’s a great question. And I think there’s a couple of different approaches. First, a couple points you’re making, one is the place to start here is with the big drivers of where we’re seeing huge price increases, and that’s really, I think, around hospitals, hospital systems. And I think that’s where we get the biggest bang for our buck initially, and there’s already regulatory efforts underway that were finalized under the previous administration requiring hospitals to disclose a set of pricing information to the public.

So I think that’s the first thing. I think for individual and smaller providers, independent providers and smaller health systems, this is not something to flip the switch on overnight, there’s a glide path here, and I think we have to really think about making sure that we’re equipping providers with the resources they need and support they need to make this meaningful. And you should be able to do what you do best, which is see your patients, take care of them, get them better. And so we have to think about that in terms of business practices as well.

The other point is, I think, there’s two sets of information here. One, there’s a set of information for consumers. Consumers need to know what our out-of-pocket costs are, and that of course is dependent, as you point out, your insurance plan, what kind of co-payments you have, your deductibles, what does your cost sharing look like? Whether you’re insured, maybe you’re not insured, where you’re getting your health insurance from, whether it’s employer sponsored or not. So there’s a lot of factors there that play into making pricing information the most meaningful for consumers. But ultimately, it’s really about what’s their out-of-pocket costs.

And so that’s a really big undertaking to be able to have a dashboard-like system or an ability for consumers to shop around. On that point, there is mixed evidence about whether pricing information like that is the most—is the way to drive value, the most effective way to drive value in the health care system. There is this other approach, which is rather than putting the burden on consumers which is important, consumers do need information about their costs, but really, we’re talking about system level costs here and putting that onus back on the system to take accountability and responsibility for disclosing payments.

So disclosing negotiated rates between plans and providers is the most valuable and most important data point there, that’s the underlying price of a service. And that’s the information that researchers need so they can analyze across markets, within markets, what does something cost? Pairing that with quality information allows you to say, where’s high value care occurring? Where is low value care occurring? And then we can inform policymakers and have better policy making around driving higher value care into the health care system.

Gordon: Yeah. I did remember reading recently that in one health system in the West Coast C-section, the cesarean section can cost, I think the number is between $8,000 and $80,000 per C-section for no really obvious reason for the difference. It’s the same thing in the different hospitals of this health system. It’s astounding to me how can we have this kind of variation. And then I read something from Kaiser Health News, there was a guy in New Jersey who was in a car crash and then had neck surgery, and he was charged $700,000 for neck surgery. It’s mind boggling. How can that happen? And he had, according to the article, he was assiduous in asking, “Is this covered? Is this a covered benefit?” And everybody told him yes, and then he got whacked with this bill. That seems to be all too common, and what do we do about that?

Sophia: All too common and totally criminal, honestly. No family, no person, no consumer should be in a position where they’re getting slapped with thousands of dollars, hundreds of thousands of dollars of bills in health care. I think what do we do about that? I think we need to, and this is happening already—people across this country, consumers across this country are getting fed up with the costs of health care. And they’re in impossible situations, almost 50 percent of the public reporting in consumer surveys that the cost of medical care is interfering with their basic needs to secure food, housing, they’re foregoing medical care. I mean, this is having such a detrimental impact on people’s lives.

And consumers are tapping into this, people are tapping into this, and we saw that around the surprise billing, the movement to end surprise billing that occurred at the end of 2020, we finally saw a legislation passed there in Congress. And we’re seeing that right now bubbling up around prescription drug prices. And I think there’s just this underlying frustration and anger that’s building from consumers in wanting to hold elected officials accountable for the policy decisions they’re making, and why are we, as consumers, continuing to bear the burden of rising costs in the health care system? So I think it’s really, at the end of the day, we have to put pressure on making some real tangible policy changes to help bring down health care costs, restore some of this market competition we were talking about earlier.

Gordon: And I think of some of the data points that you cited in the report that here we are in the US spending twice per capita of any economically on par country, the OECD countries, and yet 44 percent of Americans in one survey say they can’t afford needed care. And for all bankruptcies, 60 percent of bankruptcies in the United States are due to out-of-pocket medical costs, and we’re spending twice per person. It’s astounding to me. It gets me a little worked up as you can tell. So we need to do something different. We’ve got consolidation, we have to look at price and quality transparency, what else?

Sophia: Yeah. So the one area I’ll focus on next is really around shifting payment incentives. And this is focused on rather than way our current sort of predominant payment system works in the United States, the fee-for-service payment model, paying based on widgets of unit costs, rather than focusing on this very narrow, like, I delivered the service and now I’m getting paid for that service, that we reshape the way we think about payment and payment incentives.

And the focus is really, let dollars flow so that providers can deliver health so that they can reduce inequity, so that they can look at their patient and their whole person needs, mind, body, soul, et cetera, their mouth, their eyes, the full scope of services that people need, and rebuild payment systems to support that type of care delivery that whether you’re you need 30 minutes in an in-person visit with your doctor or a 15-minute check-in on telehealth because you’ve got a high blood pressure reading or whatever it might be, whether you need a linkage to you social services, that we’re building payment systems to support that type of care delivery model.

Gordon: Do you guys have specific recommendations, or does the group come up with those?

Sophia: Yeah. We do. And this is not all inclusive, but some of our thinking here is around this big effort, of course, health care transformation, transforming health care payment delivery systems through CMMI, Center for Medicare and Medicaid Innovation, developing new models. So one strategy is to be increasing the number of mandatory alternative payment models, that sort of alternative payment models by definition, shift economic incentives to do exactly what we were just talking about. So that’s one strategy, that we’re starting to make those types of models a more permanent part of Medicare payment.

Medicare of course, sending signals to the rest of the health care system to other payers, commercial payers to Medicaid about the direction of payments and how it sends that signal. So that’s one option for sure. I think really, what it’s going to take is continued efforts to nationally scale models that are alternative payment models, models that are using this prospective, ongoing payments that are not tied to fee-for-service, which is of course where a lot of our payment models are right now, even along the glide path to alternative payment models, and that we’re really shifting those economic incentives towards improving patient health rather than volume driven care.

And there are models right now that are already doing this, and hopefully we’ll see more come on the market, but Primary Care First, one of the newer models, Comprehensive Primary Care that attract, too. So we already have models and others in existence that we can be scaling and thinking about getting more providers into these types of models and into this type of thinking about care delivery and payment.

Gordon: There are a couple of hurdles that come to mind when I think about how this rolls out, one is that at some level, an individual clinician’s total book of income, if you don’t get above some percentage, I don’t know if it’s 50 or 60 percent of their income with this new payment model, they’re pretty much held to the old payment model. And the second issue is that if I’m an employed physician within a health care system, the new payment model may be clouds in the sky and the rain never gets down to me. It hits the system and it gets absorbed and I’m still paid on an RVU productivity, keep-running-on-the-treadmill-buddy compensation system.

Sophia: Yes. I mean, absolutely. I think there are some inherent challenges in the glide path. I think it’s 80 percent of the book of business has to be taking risks for the business model to work. I might have to verify that. But it’s pretty steep—it’s aggressive and it’s a hard—you think about primary care, independent primary care physicians who might be on a month-to-month, they don’t have big reserves, right? So I think there are some real challenges, and I think there are some other strategies for us to think through in terms of meeting providers where they are in that journey, not expecting people to go from zero to a hundred overnight, but that we are supporting providers to get on the glide path and then actually helping them move across the glide path and not stalled out.

I think right now, we are a little bit stalled out in the transition to alternative payment models and the transition to value-based care. And I think COVID-19 has really been a huge reminder that fee-for-service payment is not sustainable. And we saw a lot of practices close their doors, that risk of closing their doors. Whole sectors of a health care system that are reliant on fee-for-service really hit hard, and of course, in a moment when patients needed that access the most, you’ve seen shortages and a lot of challenges th1ere. So it’s by no means, I don’t mean to make it sound simple, like, we snap our fingers and there we are, but it is something that takes, I think, a renewed momentum right now, a continued pushing and innovative thinking to move us across this glide path and to get there.

Gordon: You had mentioned earlier about focus on primary care. Tell me more about that and why you have that focus.

Sophia: Absolutely. Well, I think primary care is the bedrock of our health care system, they’re the front line in terms of seeing patients, and they are dealing with a host of issues with patients, anything from, obviously, your physical health needs to your health-related needs that might be driving your health, to any other environmental factors that might be driving your health. And we know that 80 percent of our health and our health outcomes are actually not driven by the medical care, it’s driven by the determinants of health, the social drivers of our health. And primary care docs are really on the front lines of seeing that, of treating patients.

And historically, in terms of payment and prioritization in the health care system, they’ve very much so been underutilized, I think, not prioritized. And so I think part of our work here through Consumers First is to elevate those issues from a very basic, fundamental level of when we look at how most physicians are paid through the Medicare Physician Fee Schedule, why is it that primary care docs are reimbursed at such a lower rate compared to specialty physicians, and correcting and correcting that historical imbalance. And we did see some movement on that in the last administration, congress swept in at the end of the year and made some changes, but there’s more work to do there to make sure that primary care is getting the resources and the tools that they need to be able to be on the front lines, which is where they are.

Gordon: Yeah. I had a really interesting conversation with Christopher Koller, who’s the head of the Milbank Memorial Funds and used to be the insurance commissioner for the State of Rhode Islands. And he described the body of research showing that the more primary care physicians per 10,000 population, better mortality rates, better morbidity rates, treatment of chronic disease, life expectancy goes up. You can’t say that about the other parts of the health care delivery system. And primary care is the interface between public health and health care delivery system.

So resources applied there have a beneficial effect, and therefore in the National Academy of Science Engineering and Medicine report that recently came out, talking about reinvesting in primary care, says this is a social good, and that it’s like investing in education and investing in jobs, and that we need this as a society, there’s such a clear benefit. And so deploying resources there is the benefit to all, and then we need to shore that up, provide the funding so that they can do their work, teach them, support them in the glide path as you’ve described it, and then also hold everybody accountable.

And one of the accountability issues that Chris Koller brought up was saying to the insurance industry, you’re going to move the percent of spend on primary care from its four to seven percent level up to ten to fifteen percent. And that’s it, full stop, do that. Did the Consumers First group look at that?

Sophia: What we looked at through Consumers First was some specific policies around revaluing RVUs within the Medicare Physician Fee Schedule that would result in increased payment for primary care docs. So I mean, I think I can speak on—can’t speak on behalf of the full coalition, but I think in principle, absolutely, I think this really is about making sure that we’re investing the right resources into primary care, and both from the reimbursement side of the picture, but also from the pipeline side of the picture as well, so I think there’s a lot more work to be done there.

Gordon: So let me pivot now to the last part, and correct me if I’m wrong, but talk about data sharing and interoperability.

Sophia: Yeah. Absolutely. Data sharing and interoperability is not always the most exciting topic for folks to talk about, and it’s extremely technical, and very wonky. And I can’t say that I myself am a deep expert on data sharing and interoperability, but what I can say is it’s absolutely critical to all of the—to being able to reorient the health care system to meet people’s needs. The only way that we can really do that is if data is flowing, if it’s flowing from provider to provider, if it’s flowing from provider to plan, from plan to plan, if public health is linked in. We really need a massive overhaul to make sure that our different data systems are interoperable, that they can talk to each other.

And there’s a lot of work going on there, two rules finalized in 2020, one from ONC, one from CMS that made some really important steps forward. I know that this is a priority for ONC in the new administration, and I think a lot more work to be done there just to keep building on the efforts of making sure that we’re building national data sharing interoperability standards, that we’re moving to a place where it’s not just voluntary whether you’re going to share information, but it’s actually mandatory, we’re exchanging data.

Providers need timely, accurate, real-time data at their fingertips from a lot of different sources, a lot of different systems to be able to effectively coordinate care for their patient population in the 21st century. That’s the need, and so we got to keep pushing to make sure that we’re pushing the vendors and making sure that we’re building contracts appropriately, and that the administration is helping us build the right regulatory frameworks to do just that, while of course, I want to say of course, making sure that we are protecting patient privacy and making sure that we’re not creating any situations where there might be discrimination based on people’s health care data, it’s very, very important.

Gordon: I have this sense, one of the things that I found so exciting when I came across Consumers First is the breadth of the coalition and reading some blogs and testimony of people who were collaborating with part of, or working in the same direction. And I have the sense of this just bubbling frustration bordering on anger, bordering on, we have got to fix this now. And that’s exciting to me because I’ve also appreciate the crushing weight of the status quo and the people who drag their feet or the institutional inertia that exists across. What’s your sense of what’s going to happen in a year or two years with this?

Sophia: That’s really beautifully said. I mean, I think that’s part of the power of this coalition. When you think about large employers and consumer advocacy organizations and labor primary care providers, we don’t always agree on everything, right? We have a lot of policy positions and we might be on different sides of policy issues from each other on a lot of different areas, but on this set of issues, we are very, very aligned because of that frustration you speak to, because of the impact of growing costs on employers and what that means for employees and the tradeoffs that employers have to make in terms of wages versus cost shifting onto their employees, they don’t want to be in that position.

The same thing for consumers, feeling the brunt of rising health care costs and what that means for their tradeoffs, and they’re living paycheck to paycheck and having to make decisions about, “Do I buy that medication or do I put food on the table to feed my family?” Those are real stories from real people, and there’s a lot of them. And so there is this growing sense of frustration. This coalition is working to tap into that energy and to really provide a counterbalance to what we have seen as the status quo, as you say, to really be able to, with our aligned interests across these four sectors, labor, consumers, primary care employers, large and small, to provide that counterbalance to the interests of industry that often honestly are heard at the expense of the interest of people, and so we’re trying to flip that narrative.

I expect over the next couple of years for us to make real progress on that. Already, there has been incredible progress over the last couple of years from a lot of people’s advocacy efforts to see some reform and the practice of surprise medical bills. We’re seeing congress again, and the president himself talking about allowing Medicare to negotiate drug prices to lower prescription drug costs for consumers and employers. So I think there’s a lot of momentum on this issue of costs, the system cost, the people cost of businesses. And so I anticipate that we’ll continue to push, it’s not easy work, and the politics often make things complicated and challenging, but I do see us over the next one to two years being able to make some real important tangible steps forward on some of these issues.

Gordon: Well, if I can remember the quote right, I think it was Warren Buffet who said that American Health Care is the tapeworm on productivity and on entrepreneurship and corporations. And that gives me hope that businesses, as I’ve heard so many, like Elizabeth Mitchell from PBGH say that we have to solve this, we have to change this because what we’re buying isn’t worth the price right now. So I am so glad that you guys are on this, and keep it up, keep it going, keep the pressure, and I’m going to be right there with you so that I can appreciate a health care system that has better outcomes, is more equitable and more affordable. Thank you so much for your time today.

Sophia: Thank you very much, Gordon. We really appreciate the opportunity and I look forward to keeping the conversation going with you. And to your listeners, if they’re interested and excited about joining in the work, a big wide open invitation to reach out and to join the effort with us.

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