Legislative and Administrative Policy Developers and Health Care Payer Resources –
True collaborative, patient-centered, evidence-informed, cost-effective medicine requires transparent communication, coordination and accountability between all major stakeholders: legislative and administrative policy developers, health care payers, healthcare providers, patients and taxpayers/voters.
Patient values, clinical provider expertise and the best research available must all be given weight in the medical decision making process, including both decisions made by the patient and provider in the office and the patient outside of the office.
We must adopt health care policies (service coverages, visit limits, reimbursement rates etc.), and health care cost sharing strategies (copays, coinsurances, deductibles, premiums) that positively incentivize patients to make healthy life-style and conservative medical choices, while respecting their individual values, and provide adequate resources to them to be able to realistically expect that they will be capable of making the necessary changes on a long-term basis.
We all must be very careful not to penalize the health care clinical provider for the patient’s lifestyle choices made outside of the office, but instead develop policies that encourage the patient to make those healthy choices and then hold them accountable if they choose to continue to make poor lifestyle choices such as smoking, poor dietary choices and avoiding exercise and activity modification. We cannot deny that smoking and non genetic obesity are epidemics, and the complications and consequences of these two lifestyles cause an extreme over consumption of precious health care resources by these patients which is destroying the sustainability of our health care system.
It is the responsibility of the legislative policy makers as elected civil servants to be accountable to taxpayers and voters by ensuring that legislative and administrative policies ensure that health care payers establish policies (visit limits, limited service coverage, reimbursement rates) and cost-sharing strategies that do not create financial barriers (high copays, coinsurances and deductibles) that disincentivize patients to seek conservative cost-effective, safe treatment options and encourage them to seek to more invasive higher cost more risky health care options too early. It makes no sense to charge the patient the same $45 copay to see a neurosurgeon to have a $50,000 back surgery as a chiropractor to treat the back pain and avoid the surgery when it will take 10-15 visits at $45 each visit for the patient to complete a course of treatment. The overall costs to the system will be significantly lower with chiropractic care, but 10 times or more, higher to the patient. It also makes no sense for the patient to pay a one time $20 copay to see their PCP for a prescription of 120 narcotics. If it was purely a financial decision on the patient’s part they would choose the $20 copay for narcotics and be on their way down the rabbit hole of possible addiction and in the end never even address the issues that are causing their pain and at best cover the symptoms temporarily. Our policies are designed currently to steer patients towards narcotics and high cost invasive procedures too early.
Legislative and administrative policy makers as well as health care payers have a responsibility to assess the global impact to our economic system as a whole when developing these cost-sharing strategies and health care policies. They must understand that the global financial impact is not just the cost of the service, but the unwanted effects that the service has or may potentially have. There is no more glaring example, then the opioid epidemic we have in Vermont. The downstream social costs of addiction and covering up the symptoms of pain are staggering. We must shift our use of opioids to utilizing effective conservative musculoskeletal health care options such as chiropractic whenever possible.
Health care policy and reimbursement strategies must incentivize providers to compete to provide the highest quality and most cost-effective treatment options while protecting the patient’s individual values by realizing that not all services are appropriate for the values of all individual patients. Policy must protect and promote a diversity of effective treatment options and provider types. We must not allow monopolies of the supply of services develop and drive out individual competition, and demand disproportionately higher reimbursement rates (200% to 800% more for the same exact services). This cartel-like delivery of services drives up the cost of care for all taxpayers and residents of Vermont while driving out the small local health care providers who can provide identical services at a much lower cost. This will ultimately lead to even more limited access to clinical services and continue to drive up costs as it is currently doing.
We must identify any services that large health care provider entities provide that small providers cannot, which are a net financial loss to the provider entity (specialists who serve rare conditions, ER, etc.) and consider them as “public good” services. We should carve out a public budget to subsidize these services instead of requiring that payers have to pay more for other services to that large provider entity to offset the financial loss to the large provider entity. In this manner we can equalize reimbursement practices so that every provider whether or not they are large or small can be reimbursed the same for the same services rendered and create competition in an effort to drive down costs.
The centralization of services by a single large entity in Vermont and their ability to command a much higher reimbursement rate for the exact same services has lead to an unfair business advantage whereby the small individual providers are being forced out of practice because their very low reimbursement rates and very few if any new providers are being attracted to Vermont to replace them. The reality is that the small clinics with independent physicians are a dying breed in Vermont and it will not be long before there is only one health care provider option in Vermont which is a much more expensive option and our health care premium will truly sky rocket.