Williams: Peter, tell me, what is the Consumer-Purchaser Disclosure Project?
Lee: The Disclosure Project is a coalition of consumer, labor and employer organizations that came together about five years ago to promote ways to put better health care performance information in the hands of consumers and purchasers. We are trying to get real tools so people can make better choices with information that we’ve been lacking for all too long in health care.
Williams: One of your areas of focus has been the relative reimbursement between specialty care and primary care. Can you give me your perspective on whether procedure-oriented specialties are over-reimbursed relative to primary care?
Lee: Let me take a step back. Disclosure as a project is really about getting good measures of who is doing a good job, what treatment works, and then using those to improve care. So some of that we want used by doctors for quality improvement, some for information used by patients to make better choices. Also, you’re absolutely right, for payment. We want to make sure that information is used to steer payments so we are no longer just rewarding volume, but value. In that context, I think we share a deep concern that primary care, care coordination, and cognitive skills are under reimbursed relative to interventional specialties. That’s one of the things that we think needs to be changed when we look at payment reform.
Williams: That gap has been recognized for a while and persisted. Medicare has sustained that gap, but commercial insurers are not necessarily required to follow Medicare. So I would be interested in your perspective on why that gap has persisted both on the government side and the commercial side.
Lee: It’s a very complex set of questions. A lot of it relates to market forces. There are a lot more primary care doctors, family doctors, internists. What that means when you play that out in community after community and politically is that specialty physicians end up having more control in their local market and they’re able to hold out for and do hold out for better reimbursement. I think also politically, when it comes to Medicare reimbursement, we’ve seen a system that gives a larger voice to specialty societies even though they represent fewer people. So in Medicare’s processes through Congress, I think all too unfortunately, they are more apt to hear the focused interests of particular types of specialties.
Williams: Are you seeing any sort of shift either by CMS or by other payers towards more of a pay for performance model where that’s really starting to have an impact on the payment process or do those things tend to be more at the margin?
Lee: First of all, let’s come back to the issue of primary care and care coordination, because that’s a separate issue than paying for performance obtained through the underlying value. There is a growing recognition among both public sector payers and Congress and among major health plans and the purchasers (the employers that contract with them) that we need to shift the payment dynamics. That’s not just about paying for performance, which is often seen as on the margins. It really is the underlying issue that we need to be paying more for primary care, we need more for care coordination. I’ve seen it in virtually all the bills that are currently under consideration in Congress. There’s a very good shift in direction to say that’s what we need to shift our payments for.
Ten years ago or five years ago, a lot of the payment reform discussions were about what we might call “pay for performance,” which was taking the existing payment system and adding a little bit on if someone does a good job. I think we’re moving away from that and saying we need to look “whole hog” at redoing our payment systems. So instead, let’s pay for a bundle of services. Instead let’s make sure that doctors and hospitals are paid together so readmissions are avoided instead of paying an extra three percent if someone has a better diabetes score.
Williams: In terms of the care coordination, are you seeing concepts like the patient centered medical home as being an important part?
Lee: Yes. There is huge interest in the patient centered medical home as well as concepts that go under the rubric of accountable care organizations. We’re seeing more of an interest in the underlying concept than getting the label just right. Exactly what is a medical home? There are some good certification criteria, but they’re taking different forms.
One of the things we’ve seen in the area of payment is that there won’t be a magic bullet, but rather we need to have different payment methodologies. They will be centered around the patient instead of being centered around the doctor or the person providing the service. And one of the nice things about the medical home concept is that it’s not about an individual cowboy doctor and the individual patient. There really is a holistic concept of asking what a patient needs in terms of the range of services that might be from a primary care doctor, but also from a nutritionist, also from a nurse, etc. It really is a whole-team concept, which I think is a very important movement.
Williams: One of the interesting things about the Disclosure Project is that it really is both consumers and purchasers. Can you tell me how they work together? Often I’ve seen situations where consumer representation is token, so I’m curious as to how it’s working in your case.
Lee: One of the things that I think has been remarkable about the Consumer-Purchaser Disclosure Project is that it really is a partnership between major labor organizations such as the AFL-CIO, major employer organizations like the National Business Group on Health, the Chamber of Commerce, and consumer groups including the AARP, and the National Partnership for Women and Families. It grew out of the recognition –more than five years ago– that while these groups haven’t necessarily worked together very closely, when you step back, 99% of the interests they have are totally aligned. This includes getting higher quality, more affordable health care into the hands of consumers. It’s through that common interest and common perspective that the Disclosure Project has been a very effective forum to identify areas of common interest and then work together.
Williams: What is your perspective on the role of public reporting? There has been an emphasis on getting grades out there for doctors. They’re getting reviewed but there has been mixed evidence about whether patients or consumers really use that information. I wonder what you think about that and whether there is still value in public reporting even if the patient or consumer isn’t making much use of it.
Lee: It’s a great question. It’s a bit of the chicken and egg situation. It’s true that not huge numbers of Americans are using public reporting, but I also take issue with the “glass half-empty” perspective. We know from some of the surveys that it may be only 15% of Americans, but 15% of Americans means you’ve got over 20 million Americans using performance information to make choices about their doctors. That’s a lot of people making choices.
I’m a big believer that doctors want to do the right thing, will do the right thing, but they will do it with more speed and more focus if they know information is going to be public. So public reporting is about providing tools to consumers and putting gas in the tank so doctors and hospitals have a reason to improve even though they don’t look at report cards.
Williams: There has been a lot of emphasis and funding on health IT in the last year, even independent of health reform, as part of the stimulus package. I’m wondering how health IT and the concept of meaningful use play into the topics you’re covering, if at all.
Lee: It’s a great question. Many hold out IT as the magic bullet. The Disclosure project itself was very active in helping push for how the stimulus package legislation was written to make sure if we’re going to pay $40 billion through Medicare to have doctors and hospitals put in place health information technologies it wasn’t just to have a box in their office. It was to have meaningful use.
Meaningful use is going to be one of those new terms of art that we’re all going to come to know and understand. But at the core, what we want to make sure is that IT is actually used. You’ve got technology, which is helping doctors make better decisions and helping all of us by collecting information on performance. It really is a transformative thing to get health care out of the horse and buggy era, into an era where we have real time information to help doctors make better decisions at the point of care and real time collection of information so we can all have better information to improve.
Williams: The re-emergence of a potential public option is getting a lot of attention right now. Does it have broader relevance beyond just being something that pressures the private insurance companies?
Lee: When you look at reform the Disclosure Project per se has not take positions on the reform bill, obviously. It’s a broad coalition, but woven through the national health reform discussion and woven through each of the bills going through Congress there is very good language on how to measure health care performance and funding the new measures. There is very good language on how to have nationally standardized measures that are endorsed. There is good language on encouraging CMS to use those measures and there is good language on trying to change payment. So there are many elements that we can all be pleased to see in those reform bills.
The public plan is not a central Disclosure Project issue, but it’s essential for discussion about what the role of government is going to be and what role competition will play. The bigger issue that the public plan underscores is the challenge we have in the United States of having a market for health care and balancing the strength of providers versus the power of a price setter, whether that be a public plan or Medicare.
We need to see in the coming years that health reform ends up bending the cost curve. If it doesn’t do that we’re going to be back at the well trying to fix health care in three to five years. That’s one of the challenges that the public plan seeks to address. Whether it will succeed or not is to be determined.
Williams: If you’re to look down the path, let’s say ten years (I would say five years, but I know things don’t change that fast in health care) when we’re beyond the stimulus, the Great Recession is over, and meaningful use is likely in place, what’s your vision for how things will actually be in the US health care system and are you optimistic overall or pessimistic?
Lee: I’m mixed. You’re absolutely right to set the marker at ten years instead of five.
I will note though that I think President Obama has been both a great communicator and has used his bully pulpit well. But I also note that when he spoke to the US Congress he said that health reform had been attempted by Presidents Roosevelt, Truman, Nixon, Johnson, and Clinton and said he would be the last since he would succeed. I think where he got it wrong was fixing health care and having it be improved is an ongoing process. If reform passes this year, it’s going to be more of a starting line issue than a finish line.
When I look ten years out, I am hopeful that there will be a far different set of payment arrangements that will be rewarding care coordination. They will be supporting doctors and hospitals with better information technology. They will be supporting patients with information so they can make the choices that are right for them. I think it’s going to be not a revolution as much as an evolution of the whole range of systems.
Williams: I’ve been speaking with Peter Lee. He is Co-Chair of the Consumer Purchaser Disclosure Project and also Executive Director of National Health Policy of the Pacific Business Group on Health. Peter, thank you very much.