What are some of the major public health issues facing the US health services system?

Healthcare executives rank the top 10 transformational themes for 2020. 

More than 100 C-suite and director-level executives voted on and then ranked the top 10 critical challenges, issues, and opportunities they expect to face in the coming year, during the 2019 HCEG Annual Forum. The HealthCare Executive Group (HCEG), a 31-year-old networking and leadership organization, facilitated discussion around the issues the Forum, which took place September 9 to 11, in Boston.

Executives from payer, provider, and technology partner organizations were presented with a list of more than 25 topics. Initially compiled from webinars, roundtables, and the 2019 Industry Pulse Survey, the list was augmented by in-depth discussions during the Forum, where industry experts expounded on a broad range of current priorities within their organizations. HCEG Board Members announced the results of the year-long process that determined the 2020 HCEG Top 10 Challenges, Issues, and Opportunities.

1. Costs and transparency. Implementing strategies and tactics to address growth of medical and pharmaceutical costs and impacts to access and quality of care.

2. Consumer experience. Understanding, addressing, and assuring that all consumer interactions and outcomes are easy, convenient, timely, streamlined, and cohesive so that health fits naturally into the “life flow” of every individual’s, family’s and community’s daily activities.

3. Delivery system transformation. Operationalizing and scaling coordination and delivery system transformation of medical and non-medical services via partnerships and collaborations between healthcare and community-based organizations to overcome barriers including social determinants of health to effect better outcomes.

4. Data and analytics. Leveraging advanced analytics and new sources of disparate, non-standard, unstructured, highly variable data (history, labs, Rx, sensors, mHealth, IoT, Socioeconomic, geographic, genomic, demographic, lifestyle behaviors) to improve health outcomes, reduce administrative burdens, and support transition from volume to value and facilitate individual/provider/payer effectiveness.

5. Interoperability/consumer data access. Integrating and improving the exchange of member, payer, patient, provider data, and workflows to bring value of aggregated data and systems (EHR’s, HIE’s, financial, admin,  and clinical data, etc.) on a near real-time and cost-effective basis to all stakeholders equitably.

6. Holistic individual health. Identifying, addressing, and improving the member/patient’s overall medical, lifestyle/behavioral, socioeconomic, cultural, financial, educational, geographic, and environmental well-being for a frictionless and connected healthcare experience.

Related:The Future of Healthcare Leadership

7. Next-generation payment models. Developing and integrating technical and operational infrastructure and programs for a more collaborative and equitable approach to manage costs, sharing risk and enhanced quality outcomes in the transition from volume to value (bundled payment, episodes of care, shared savings, risk-sharing, etc.).

8. Accessible points of care. Telehealth, mHealth, wearables, digital devices, retail clinics, home-based care, micro-hospitals; and acceptance of these and other initiatives moving care closer to home and office.

9. Healthcare policy. Dealing with repeal/replace/modification of current healthcare policy, regulations, political uncertainty/antagonism and lack of a disciplined regulatory process. Medicare-for-All, single payer, Medicare/Medicaid buy-in, block grants, surprise billing, provider directories, association health plans, and short-term policies, FHIR standards, and other mandates.

10. Privacy/security. Staying ahead of cybersecurity threats on the privacy of consumer and other healthcare information to enhance consumer trust in sharing data. Staying current with changing landscape of federal and state privacy laws.

“We are seeing more change in the 2020 HCEG Top 10 than we have seen in recent years and for good reason. HCEG member organizations express that the demand for, and pace of change and innovation is accelerating as healthcare has moved to center stage in the national debate. It shouldn’t be surprising that costs and transparency are at the top of the list along with the consumer experience and delivery system transformation,” says Ferris W. Taylor, Executive Director of HCEG. “Data, analytics, technology, and interoperability are still ongoing challenges and opportunities. At the same time, executives need to be cautious, as individual health, consumer access, privacy, and security are on-going challenges that also need to remain as priorities.”  

Turning challenges into opportunities

Reducing costs means lower revenue for providers and almost all of the players in healthcare––except for consumers and payers, says Mark Nathan, CEO and founder of Zipari, a health insurtech company. So while there are many incentives to keep healthcare costs high, if consumers are provided with the information they need to improve their health and drive down their personal costs, then we could see consumers en mass making decisions that drive down costs across the industry, he adds.

“Predicting cost in the traditional health insurance environment is shockingly complex,” Nathan says. “The most advanced payers can simulate claims and predict the cost of procedures. However, as you layer in full episodes of care, such as knee surgery, it becomes much harder to accurately predict the patient's total out-of-pocket cost. Bundled value-based payments start to make cost transparency a little easier to predict, but most plans still have a way to go to get to that type of offering.”

The greatest opportunity to drive down health costs––for payers, consumers, and system-wide––is with the payer-consumer relationship, he says. “Payers have the information consumers need to make better decisions about their health and finances––if plans can build positive and trusted relationships with their members. Once a payer proves it can make valuable and trusted recommendations, the consumer can make the decisions that will not only lead to better health outcomes but also to reduced cost of care.”

Staying Healthy

Here’s a question that’s been on my mind and perhaps yours: Is the US healthcare system expensive, complicated, dysfunctional, or broken? The simple answer is yes to all. Below are 10 of the most convincing arguments I’ve heard that our system needs a major overhaul. And that’s just the tip of the iceberg. Remember, an entire industry has evolved in the US just to help people navigate the maddeningly complex task of choosing a health insurance plan.

The cost is enormous

• High cost, not highest quality. Despite spending far more on healthcare than other high-income nations, the US scores poorly on many key health measures, including life expectancy, preventable hospital admissions, suicide, and maternal mortality. And for all that expense, satisfaction with the current healthcare system is relatively low in the US.
• Financial burden. High costs combined with high numbers of underinsured or uninsured means many people risk bankruptcy if they develop a serious illness. Prices vary widely, and it’s nearly impossible to compare the quality or cost of your healthcare options — or even to know how big a bill to expect. And even when you ask lots of questions ahead of time and stick with recommended doctors in your health insurance network, you may still wind up getting a surprise bill. My neighbor did after knee surgery: even though the hospital and his surgeon were in his insurance network, the anesthesiologist was not.

Access is uneven

• Health insurance tied to employment. During World War II, healthcare was offered as a way to attract workers since employers had few other options. Few people had private insurance then, but now a layoff can jeopardize your access to healthcare.
• Healthcare disparities. The current US healthcare system has a cruel tendency to delay or deny high-quality care to those who are most in need of it but can least afford its high cost. This contributes to avoidable healthcare disparities for people of color and other disadvantaged groups.
• Health insurers may discourage care to hold down costs. Many health insurance companies restrict expensive medications, tests, and other services by declining coverage until forms are filled out to justify the service to the insurer. True, this can prevent unnecessary expense to the healthcare system — and to the insurance company. Yet it also discourages care deemed appropriate by your physician.

  This can make for shortsighted decisions. For example, when medications are prescribed for rheumatoid arthritis, coverage may be denied unless a cheaper medication is prescribed, even if it has little chance of working. A survey (note: automatic download) found that 78% of physicians reported that this led people to abandon recommended treatments; 92% thought it contributed to care delays. And because the expensive medication may prevent future knee or hip replacements, delay may ultimately prove more costly to insurance plans and patients while contributing to more suffering.

Investments in healthcare seem misdirected

• Emphasizing technology and specialty care. Our system focuses on disease, specialty care, and technology rather than preventive care. During my medical training, I received relatively little instruction in nutrition, exercise, mental health, and primary care, but plenty of time was devoted to inpatient care, intensive care units, and subspecialties such as cardiology and gastroenterology. Doctors practicing in specialties where technology abounds (think anesthesiology, cardiology, or surgery) typically have far higher incomes than those in primary care.
• Overemphasizing procedures and drugs. Here’s one example: A cortisone injection for tendinitis in the ankle is typically covered by health insurance. A shoe insert that might work just as well may not be.
• Stifling innovation. Payment structures for private or government-based health insurance can stifle innovative healthcare delivery. Home-based treatments, such as some geriatric care and cancer care, may be cost-effective and preferred by patients. But, because current payment systems don’t routinely cover this care, these innovative approaches may never become widespread. Telehealth, which could bring medical care to millions with poor access, was relatively rare before the pandemic, partly due to lack of insurance coverage. And yet, telehealth has flourished by necessity, demonstrating how effective it can be.
• Fragmented care. One hallmark of US healthcare is that people tend to get care in a variety of settings that may have little or no connection to each other. That can lead to duplication of care, poor coordination of services, and higher costs. A doctor may prescribe a medicine that has dangerous interactions with other medicines the person is taking. Medicine prescribed years earlier by a doctor no longer caring for a person may be continued indefinitely because other doctors do not know why it was started. Often doctors repeat blood tests already performed elsewhere because results of the previous tests are not readily available.
• Defensive medicine. Medical care offered primarily to minimize the chance of getting sued drives up costs, provides little or no benefit, and may even reduce the quality of care. Malpractice lawsuits are so common in the US that for doctors in certain specialties, it’s not a matter of if but when they are sued. Though it’s hard to measure just how big the impact of defensive medicine is, at least one study suggests it’s not small.

No simple solution

Even insured Americans spend more out of pocket for their healthcare than people in most other wealthy nations. Some resort to purchasing medications from other countries where prices are far lower. The status quo may be acceptable to healthcare insurers, pharmaceutical companies, and some healthcare providers who are rewarded handsomely by it, but our current healthcare system is not sustainable (note: automatic download).

Other countries have approached healthcare quite differently, including single-payer, government-run systems, or a mix of private and public options. Perhaps some of the most successful can serve as a model for us. But, with so much on the line and competing interests’ well-funded lobbying groups ready to do battle, it’s far from clear whether reform of our healthcare system can happen anytime soon.

I haven’t met many patients who think our current healthcare system is great. In fact, I don’t know anyone who would design the system we currently have — well, other than those who are profiting from it.

The question going forward is whether there will be the trust, will, and vision necessary to build something better. It won’t be easy, but the alternative — continuing to complain while waiting for the system to implode — is unacceptable.

Follow me on Twitter @RobShmerling

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio

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Comments

What a great article. Thank you so much for discussing how our current healthcare system simply isn't working for millions of people. This is unacceptable. It has been this way for far too long and far too many people have had to and continue to suffer due to our grossly negligent and inadequate healthcare system in the US.

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