At what point is optimal cost-effectiveness achieved in the delivery of medical care?

Introduction

The role of government in health care has expanded over the years and influenced political discourse and policy. Whether this is an appropriate role has been contested. Still, the government, with extensive programs and market influence, is likely to play a major role in achieving better quality and value in health care and in the success or failure of lasting healthcare reform. This paper attempts to describe current efforts of the government to improve quality and value in the healthcare system by discussing the Affordable Care Act (ACA) of 2010 and various “drivers” the government uses.

The U.S. spends more per capita on health care than any other nation in the world.

Yet the measured outcomes of the care provided are no better than, and are often inferior to, outcomes achieved by other developed nations that spend substantially less (Organization for Economic Co-operation and Development).

Moreover, best-practices guidelines for healthcare delivery are not followed routinely, and wide geographic variations exist in healthcare costs and quality.

Healthcare costs have increased over the past 3 decades and consume an increasing share of the U.S. Gross Domestic Product (GDP), now accounting for a greater percentage of GDP than any other sector of the U.S. economy.

Federal leadership has been stimulated anew under the ACA and numerous other pieces of recent healthcare legislation. As a result, the role of government in the U.S. healthcare system is being contested more than ever. Several studies have researched the role government can play in the management of healthcare costs and have presented several arguments. Although views on the value and appropriateness of government involvement may differ, there is consensus that government is a major stakeholder in combating rising healthcare costs.

Federal Involvement in Healthcare Quality, Value, and Prevention

The federal government has played a major role in health care over the past half century from the establishment of Medicare and Medicaid in 1965—ensuring access to insurance coverage for a large portion of the U.S. population—to multiple pieces of legislation from the 1980s to early 2000s that protect individuals under employer-sponsored health insurance and expanded federal healthcare programs. Federal government influence has resulted in public programs that, in 2008, led to expenditures of $1.11 trillion.

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Further, the laws, regulations, policies, payment systems, and oversight of these huge federal programs have major direct and indirect influences on private-sector payers and the health care that is delivered to Americans not covered under federal programs.

Because of its influence, the government has played an important role in promoting the use of preventive services. It also has promoted increased recognition of how disease prevention contributes to healthcare efficiency and cost-savings. Originally, Medicare was not allowed to authorize primary preventive services. Specifically, “screening tests” were expressly excluded as a benefit under Medicare, and that general exclusion continues to the present day. It was not until 1980 that the U.S. Congress authorized the first specific prevention screening benefit for Medicare beneficiaries. Since that time, Congress has added separately benefit status to some preventive services as recommended by various bodies responsible for preventive services guidelines.

More recently, under Section 101 of the Medicare & Medicaid Improvements for Patients and Providers Act (MIPPA) of 2008, Congress authorized the Secretary of DHHS to add additional preventive services to the Medicare benefit structure via the National Coverage Decision (NCD) process of the Centers for Medicare & Medicaid Services (CMS). This is a major advance in facilitating prevention benefits and coverage in the Medicare program, albeit with limitations. Because Medicare decision-making with respect to what services are/are not covered influences Medicaid, its Children's Health Insurance Program (CHIP), and private-sector payers, it presents an important opportunity for federal healthcare policy to promote preventive services as necessary for optimal individual healthcare delivery and address public health issues.

The Affordable Care Act and Preventive Health Care

The most recent, and potentially most influential, federal healthcare legislation is the ACA. It illustrates how federal legislation can address the inadequacies of current federal healthcare efforts by promoting greater emphasis on disease prevention and health promotion as essential building blocks of overall healthcare reform, improving health outcomes, and reducing healthcare costs. The ACA is divided into 10 major titles. One of them, Title IV: Prevention of Chronic Disease and Improvement of Public Health, is devoted entirely to prevention issues and initiatives. Prominent subtopics addressed in this legislation include modernizing disease prevention and public health systems, increasing access to clinical and community-based preventive services, launching education and outreach campaigns regarding the benefits and use of preventive services, providing support for prevention and public health innovation, and supporting wellness programs.

Title IV, Subtitle A, Section 4001, directed the President to establish, within DHHS, the National Prevention, Health Promotion and Public Health Council. In addition to having presidential oversight, the council includes members from a comprehensive list of government agencies. Chaired by the Surgeon General of the U.S., the council is perhaps the highest-level and broadest administrative group in the Executive Branch, save the Cabinet.

On June 16, 2011, the council issued a 125-page report titled “National Prevention Strategy.” Its vision was “working together to improve the health and quality of life for individuals, families, and communities by moving the nation from a focus on sickness and disease to one based on prevention and wellness.” Its overarching goal was to “increase the number of Americans who are healthy at every stage of life.”

The report set four strategic directions: building healthy and safe community environments, expanding quality preventive services in clinical and community settings, empowering people to make healthy choices, and eliminating health disparities. Its seven targeted priorities were tobacco-free living, prevention of drug/alcohol abuse, healthy eating, active living, injury/violence-free living, reproductive/sexual health, and mental/emotional well-being. For each of the directions and priorities, the report made multiple specific, evidence-based recommendations.

In addition, the report detailed specific actions to which the federal government would commit and outlined evidence-based actions that partners, businesses, employers, healthcare systems, insurers, clinicians, educational organizations, community/nonprofit/faith-based organizations, individuals, and families could implement to complement federal activities. The report also stressed the collaborative nature of priority setting and the importance of continuing that collaborative process involving all healthcare stakeholders in goal setting, design, implementation, and accountability. The Agency for Healthcare Research and Quality (AHRQ) was designated the lead, with assistance of other DHHS agencies, to develop more-specific details for the plan.

Just a few months before the council's report was issued, DHHS submitted its own report, the “National Strategy for Quality Improvement in Health Care,” to Congress in March 2011.

The six national priorities identified were making care safer by reducing harm caused in the delivery of care; ensuring that each person (and family) is engaged as a partner(s) in patient care; promoting effective communication and coordination of care; promoting the most effective prevention and treatment practices for the leading causes of mortality; working with communities to promote the use of best practices to enable healthy living; and making high-quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare-delivery models.

The Affordable Care Act and the Barrier of Cost-Sharing

The ACA included recognition that recommended preventive services are used at levels far below desired utilization. Cost-sharing for these services by patients, including copayments, co-insurance, and deductibles, was cited as a barrier to achieving desired rates. Subsequent to ACA requirements, a regulation was issued jointly by DHHS, the Department of Labor, and the Department of the Treasury requiring health plans to cover a prescribed list of recommended evidence-based preventive services and eliminate cost-sharing as of September 23, 2010. The list of covered services spans routine adult services; a comprehensive list of children's services/screenings/counseling; women's and infant's services; and a number of disease-specific services for cardiac disease, obesity, cancer, diabetes, and other chronic illnesses. The legislation facilitates additions to the list, as evidence becomes available that confirms the efficacy of such services.

The Centers for Medicare & Medicaid Services' Role in Improving Healthcare Quality and Value

Beyond the ACA, federal healthcare agencies, particularly CMS, have long had statutory authority to effect change in the U.S. healthcare system. This authority, when used effectively, wields a great deal of power to address deficiencies in the quality and value of health care provided to the public. This authority extends beyond federal healthcare programs to affect the private sector, including providers, payers, and health plans; state and local government; pharmaceutical and device manufacturers; other suppliers; and myriad other categories of healthcare stakeholders.

The Centers for Medicare & Medicaid Services as a prototype, for example, can apply various drivers, alone or in combination, that have power to catalyze and hasten prevention efforts, improve patient-centered outcomes, and maximize value in the U.S. healthcare system. These drivers are available at the federal and state level, are arguably not used to their maximum effect, and are also variably applicable to private commercial healthcare-sector payers, employers, integrated health systems, healthcare collaboratives, and other healthcare stakeholders.

These drivers emphasize traditional quality improvement but with evidence-based interventions and accountability for improved outcomes that can be attributed to the funding and interventions claimed to cause the change. But they also can be used to implement many recommendations of the “National Prevention Strategy.” Traditionally, CMS has relied on its Quality Improvement Organization (QIO) Program and End-Stage Renal Disease (ESRD) Network Program to target improvements in healthcare quality, but there are many examples of broader collaborations and efforts outside these formal programs that the federal government could lead.

Other Federal Drivers of Prevention

Increased Healthcare System Transparency

Increased healthcare system transparency is beginning to take place through public reporting and Internet-based dissemination of healthcare data (predicated on widespread adoption and “meaningful use” of health information technology). Currently, a number of preventive services and health promotion metrics are reported publicly via a variety of CMS and DHHS websites, most notably the CMS “Compare” websites. These websites report provider-level process and outcomes, and continue to grow in terms of the amount of data they contain.

This information can be used for a variety of purposes. Applications include monitoring progress toward goals, setting benchmarks, allowing consumers to choose providers or sites of care, assisting payers in rewarding better quality and value, and aiding policymakers and researchers in their work. Increasing the number of prevention/wellness measures and settings measured (e.g., information on states, communities, organizations, and systems) is needed to implement the National Prevention Strategy.

Payment System Incentives

Another driver is alignment of healthcare reimbursement with better quality and value. Vehicles for achieving this goal include value-based purchasing (VBP); pay-for-performance (P4P); withholding penalties; gain-sharing; accountable care organizations (ACOs); and medical homes.

Strategic Use of Regulation

Regulation, as a driver, includes setting quality standards and processes through conditions of participation (CoPs) or conditions for coverage (CfCs) and ensuring compliance. All DHHS agencies and many other federal agencies produce regulations that can motivate/require better prevention and health promotion.

Evidence-Based Decision Making

Evidence-based decision making, as a driver, must be supported by increased comparative-effectiveness research and cost-effective analysis. Using research results from these types of studies, the federal coverage process can try to balance promotion of technology innovation with avoidance of wasteful/unnecessary technology (and unproven technology); treatments; pharmaceuticals; devices; and medical services, including those relating to preventive and wellness services.

Conclusion

The federal role in health care has expanded over the years. It is likely to play a major role in achieving better quality and value in health care and the success or failure of healthcare reform more generally. The U.S. healthcare system, as a major segment of the U.S. economy, faces serious challenges that threaten its output and viability. Chronic disease is a major contributor to healthcare expenditures and, although prevention and health promotion efforts have not been optimal, they can play an important role in improving health outcomes.

Many evidence-based prevention interventions and initiatives have been identified, but progress has eluded the country as a whole. Federal leadership has been stimulated under the ACA of 2010 and numerous other pieces of healthcare legislation that provide powerful “drivers” of healthcare quality and value improvement, particularly for prevention and health promotion efforts. Whether or not federal efforts will succeed is arguable, but without them national progress seems unlikely.

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DOI: https://doi.org/10.1016/j.amepre.2012.09.009

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