A Reform Wish List

From the front lines of patient advocacy
February 4, 2010 -- Though the national debate over healthcare reform is far from over, most sympathizers now agree on common objectives, including universal access to quality care at an affordable cost, a focus on prevention, evidence-based medicine, electronic medical records, and a patient-centered approach. 
However these worthy goals ultimately are met, consumers will be served best if reforms embrace three common principles: transparency, simplicity, and accountability. From the front lines of my organization’s work with diverse patients and families, I humbly submit five key ways reformers and their allies can put these principles into practice.
1. Protect the Integrity and Flexibility of the Provider-Patient Relationship
Right now it is easy to forget the lessons learned during the HMO “revolution” in the 1980s: providers and patients do not want faceless insurance bureaucrats influencing diagnosis and treatment decisions, nor do they want to be motivated by anything other than assuring the best care possible. In our current national focus on reducing waste, standardizing practices, and reining in costs, we must learn from the past and improve on the present.
            Maintain Coverage Parity for Medical Necessity
We can and must change compensation practices to reward prevention and efficiency, but reforms should not prevent providers and patients from making sound medical decisions. For instance, in seeking to reduce excess costs from elective hysterectomies, carriers should not be permitted to charge higher deductibles or reduce coverage for the procedure when it is medically necessary. The same is true with MRI scans or other tests and procedures that are often over-used. Insurance reform should expressly protect the right of providers and patients to receive similar coverage for diagnostic and treatment plans warranted by the unique circumstances of each case. 
            Maintain Flexibility in Provider Choice
Medicine is constantly evolving, and providers possess diverse skill-sets, personalities, institutional resources, and levels of experience. Especially for patients with hard-to-treat conditions, finding the right provider can lead to big differences in outcomes. Reforms should protect patient access to second opinions and out-of-network referrals when the stakes are high. And doing so should not require hours of paperwork, appeals, or the help of a professional advocate.
Share Potential Conflicts of Interest With Patients
The sanctity of the provider-patient relationship depends on trust. The vast majority of providers want the best for their patients, but studies show that outside financial incentives—such as an ownership stake in a scanning center, drug rebates, or shares in a medical device company—can subtly influence physician recommendations. Biases like these can persist even when providers or researchers consciously seek to avoid them.
Providers should candidly reveal potential conflicts of interest when discussing diagnosis and treatment alternatives with patients. If a provider and patient conclude that a potential conflict of interest does not change the best course of action, so be it. But let the provider and patient decide together, openly.
2. Require Full Disclosure of Patient Advocacy and Education Group Funding
Potential conflicts of interest concern not just providers, but advocacy and research groups as well. Many patient advocacy groups receive the lion’s share of their funding from interests within the healthcare industry, such as pharmaceutical companies. While industry sponsorship may not necessarily compromise organizational independence, money can and does talk. Take, for instance, the proliferation of “informational” websites designed to sell a specific drug, or nonprofit patient advocacy groups that stay quiet in Congress when their industry sponsors get upset.
Consumers should not have to dig through databases and federal filings to discover who funds healthcare advocacy groups. Instead, such information should be prominently disclosed on web sites and in promotional materials.
3. Radically Simplify Medicare and Crack Down on Deceptive Sales Tactics
Our Byzantine Medicare plan selection process is a mess. In most states, there are several dozen difficult-to-compare prescription drug, medical, and supplemental plans to choose from (not to mention overlapping “extra help” and other subsidy programs). The consequences of making a poor choice can be staggering: many enrollees go without needed drugs or pay far more than they need to for their care.
Selecting plans should be simpler and more transparent. The federal government can further simplify and standardize plan types so that enrollees can quickly and easily understand their choices. State and federal regulators should also crack down on deceptive sales tactics. Medicare plan sponsors are notorious for advertising “free” or “expert” Medicare navigation workshops that are actually designed to sell specific plans. Regulators should tighten advertising rules to stop these and other deceptive sales pitches.
4. Radically Simplify the Private Insurance Market
The private insurance market is almost as daunting for consumers as Medicare. Most Americans now piece together and compare their options haphazardly (if they compare them all). It doesn’t need to be this way. A transparent state insurance exchange could go a long way toward simplifying the selection process. A well-designed online exchange, drawing on lessons learned in Massachusetts and elsewhere, could put consumers in the driver’s seat.
Brokers can also help make the insurance selection process more transparent by disclosing how much they are compensated for selling specific plans. If a higher priced plan really is the best fit for a customer, then there should be no shame in sharing the payment terms. Brokers can also support a uniform “per member per month” compensation scheme across all plans to reduce the appearance of bias.
5.   Ensure that Patients Can Access and Audit Their Electronic Records
Nobody is more familiar with a patient’s history than the patient. While new federal standards offer safeguards for protecting the privacy of electronic medical records (EMRs), rules governing patient access and review are still under-defined. In any EMR system, patients must have hassle-free access to their full record and a straightforward means to correct errors and omissions. No consumer should have to endure the costs, bureaucratic hoops, and delays we now see in other areas, such as credit reporting.
I realize that these suggestions might strike some as relatively trivial in the face of bigger challenges, and others as irritating or even offensive. But virtually all of us are patients at some point in our lives. Imagine yourself as a patient, and then the urgency and reasonableness of these pleas are easier to appreciate. With empowered consumers working as full partners in their care, we have a real chance at achieving better outcomes for everyone at a lower cost. 
Jason McNichol, PhD, is president of Health Advocacy Solutions, an independent healthcare consumer support nonprofit, and a lecturer in the Department of Sociology at Portland State University.


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Comments to various items are discussed: 1. If the US would by and large disavow a fee-for-service system tainted by the profit motive and instead accept a capitated health system (see VA and Kaiser), the usual HMO issues would either disappear or look very different. Cost efficiency would be very carefully weighed against the threat of malpractice litigation and the result most likely would be optimum quality of evidence-based care while abiding by the principles of medical necessity. A single-payer system will not remedy our current problems if still fee-for-service driven - because it muddles everything and will be an eternal barrier to sanity in US health economics. It is also the major hurdle against keeping Medicare solvent, with its huge cost overruns and thousands of pages of regulations. One automatic benefit of a capitated health system would be a constant emphasis on prevention. 2. Economic conflicts of interest simply should not exist for medical providers such as physicians; revealing them to patients solves nothing. Other ethical conflicts such as related to end-of-life issues have a different flavor altogether. Advocacy groups and websites supported by corporte interests should be indentified, no doubt. 3. & 4. Could be largely solved with comments in #1 above. 5. I could not agree more.