The Access Group, Berkeley Heights, NJ
Dr Guerin is the senior director for Government Policy System and Analytics for The Access Group. Dr Stefanacci is the chief medical officer for The Access Group, a managed markets agency for pharmaceutical companies.
J Clin Pathways. 2017;3(1):37-39.
As the Republican party gains control over federal health care policy, it seems likely that patients will have much more involvement in their health care in terms of decision-making capacity and out-of-pocket expenses. This means that they will be entering health systems in need of patient-friendly clinical pathways that clearly articulate treatment value propositions in terms of patient costs and measures that matter to patients such as quality of life.
As the Republican party gains control over federal health care policy, assumptions can be made regarding what health care will look like based on what has already been proposed by those who will be in positions to make decisions about health care policy. With the nomination of Tom Price, MD, to head the US Department of Health and Human Services, the health care legislation he has proposed in the last three sessions of Congress, the bill Empowering Patients First Act (H.R. 2300),1 has become an important indicator of future health care policy. Similarly, House Speaker Paul Ryan’s health care proposal based on Dr Price’s bill, the Republican-sponsored A Better Way initiative,2 also provides a useful guide to likely changes to the health care system.
Speaker Ryan’s proposed plan begins with a full repeal of the Affordable Care Act (ACA) and outlines a restructured health care system that provides people flexibility in purchasing the health care coverage they want through health savings accounts (HSAs) and high-deductible health plans (HDHPs) partially subsidized through age-adjusted (not income-adjusted) tax credits. The authors state the guiding principle behind this approach is that “unleashing the power of choice and competition is the best way to lower health costs and improve quality.”2
It is important to note this consumer-directed model has been tested in the state of Indiana, the home state of the former Governor and current Vice President, Mike Pence, since 2008. In what is currently known as the Healthy Indiana Plan,3 Medicaid recipients are provided a HSA-type of an account that is funded by both the state and the recipient and is used to pay deductible expenses and co-payments for nonemergency use of hospital emergency departments; other hospital costs are covered by the state. In addition, incentives are provided for preventive care; however, if the recipient does not contribute to their HSA, they are “locked out” of their plan for 6 months. The Healthy Indiana Plan has been in effect for 8 years and, according to the State, has claims data and actuarial analysis demonstrating very strong and positive results.3
The Republican vision for health care on a federal level is likely to follow this same patient-empowering and consumer-directed model in several ways. As can be seen in Table 1, the biggest change in Medicaid will be determined by what type of funding states will receive from the federal government. The A Better Way proposal2 suggests that moving to a block grant or capitated plan would help to control federal costs and, at the same time, give states the freedom to run their Medicaid programs in a way that is optimized for their populations. In addition, Medicaid recipients will have the option of taking a tax credit equivalent to their health care costs and purchase their own policy that will be made available through individual plans or individual health pools (available across state lines). A model that incorporates the consumer-directedness of the Healthy Indiana Plan and the flexibility of state-level controls of funds as described in A Better Way is likely to be a core component of Republican-led health care reform.
The ACA’s health care exchanges would be discontinued and replaced by the ability for anyone to purchase health insurance directly or through insurance pools set up to include larger groups of people, which may reduce costs. The costs would be partially subsidized through the same age-adjusted tax credits mentioned above. People with commercial insurance would have the same option to continue with their employer coverage or opt out and use their tax credit to purchase coverage on their own. One caveat is that health care coverage will be a taxable item for plans where costs exceed specific dollar amounts, similar to the ACA’s controversial “Cadillac Tax” on high-value benefits. Medicare beneficiaries will also have the option to opt out and purchase health insurance on their own with the same tax credits.
One significant change proposed for Medicare is the expanded use of value-based insurance design (VBID) in Medicare Advantage (MA) plans. The authors of the A Better Way proposal2 believe that the current MA plan design is a limited one-size-fits-all policy. A VBID would give insurers the flexibility to design plans that push providers and beneficiaries to make decisions together to promote high-value services and minimize low-value, unnecessary services.
As we can see, the Republican plan imbeds customer-driven aspects throughout the private and public health care designs. Assuming some version of this plan will eventually be adopted, organizations that design and implement clinical pathways will need to adapt to address the needs and expectations of patients. In order to do this effectively, we need to understand what constitutes a consumer-driven pathway.
What is a Consumer-Driven Clinical Pathway?
A consumer-driven pathway is one that contains a high degree of patient centricity. From an oncology perspective, Dr Joseph Alvarnas, editor-in-chief of Evidence-Based Oncology, believes that, despite improvements in cancer care technology, our delivery system “…remains quite inefficient and frequently falls short of being truly patient-centered.”4 Dr Alvarnas goes on to state that, according to the Institute of Medicine, 30% of all health care dollars are spent on services—such as tests, procedures, and physician and hospital visits—that are in fact unnecessary.
Increased costs related to poor patient-centered care result from variabilities in clinical decision-making and therapeutic selection and ineffective care coordination and end-of-life strategies. Clinical pathways that appeal to patients and caregivers will be those that provide greater transparency around care decision-making and therapeutic selection and that manage intra-provider care coordination more effectively. With such an approach, the patient and physician will be better able to “navigate the tension” between personalized medicine and population-based care and align with patient priorities such as quality of life.
Critics claim that pathways are currently being used by payers to force physicians into prescribing therapies preselected by insurance companies based purely on cost considerations, thus limiting access to care options that may be costly but heavily valued by patients given their high prioritization of quality-of-life outcomes. The critical point in developing pathways that align with the patient’s needs are those developed by health care providers that have the patient’s perception of value in mind, which is often tied to patient out-of-pocket costs and quality-of-life outcomes. A few ways this can be accomplished is by designing pathways that support shared decision-making and provide a way for the patient to provide their input into their treatment priorities, creating a personalized treatment plan.5
In addition to patient values, future consumer-driven clinical pathways will need to provide for greater patient engagement. For example, from the perspective of diabetes, a consumer-driven pathway will incorporate the use of innovative patient engagement tools addressing cultural differences and health literacy of patients to help patients overcome barriers to managing their diabetes.6
For other takes on this topic, read the Counterpoint: "In the Next Generation of Value-Based Contracting, Clinical Pathways Can Increase Accountability."
As our health care system prepares for greater patient involvement, clinical pathways that move beyond payer-focused cost and provider-focused quality measure, instead providing guidance to patients on value in terms of their out-of-pocket and quality-of-life outcomes, will become essential.
1. 114th Congress. Empowering Patients First Act of 2015. H.R. 2300. https://www.congress.gov/114/bills/hr2300/BILLS-114hr2300ih.pdf. May 13, 2015. Accessed December 8, 2016.
2. Paul Ryan, Speaker of the House. A Better Way: Our Vision for a Confident America. Health Care. http://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf. Published June 22, 2016. Accessed December 7, 2016.
3. The Lewin Group, Inc. Indiana Healthy Indiana Plan 2.0: Interim Evaluation Report. July 6, 2016. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-interim-evl-rpt-07062016.pdf. Accessed December 8, 2016.
4. Alvarnas J. Patient-centric cancer care delivery. Evidence-Based Oncology. 2016; 22(Special Issue 5):SP153.
5. Balch A. Putting patients at the center of the clinical pathways debate. The Catalyst. August 19, 2015. http://catalyst.phrma.org/putting-patients-at-the-center-of-the-clinical-pathways-debate. Accessed December 8, 2016.
6. Stefanacci RG, Guerin S. Diabetes clinical pathways: Going beyond treatment decisions. Journal of Clinical Pathways. 2016;2(suppl 1):S7-S9.