Revise Health Policy
Up to one in four people can't get the medical care they need, due to cost. But researchers at the U-M Center for Value-Based Insurance Design (V-BID) think that number could be sharply reduced - and health outcomes improved — by implementing what they describe as "clinically nuanced" benefit design.
"By clinical nuance," explains V-BID Center Director and SPH Professor Mark Fendrick, "we mean that medical services differ in the benefit provided, and that the clinical benefit of a specific service depends on who receives it, as well as on when and where the service is provided." Fendrick and his V-BID team believe clinical nuance should be incorporated into both commercial health plans and Medicare - so that health-producing treatments cost consumers less, and treatments that don't produce health hit consumers' wallets more.
That's easier said than done. Because of anti-discrimination language in the original 1965 Medicare legislation, current regulations make it impossible to tailor Medicare benefits for specific patient populations, such as people with certain chronic diseases. Yet with the growing move toward precision medicine, "precision benefit design makes all kinds of sense," Fendrick says.
To date, V-BID's greatest accomplishment—part of the Affordable Care Act - has been to eliminate the out-of-pocket costs for selected primary preventive services, such as vaccines for kids and colonoscopies for those over age 50, for over 137 million people. But as valuable as preventive care is, it only generates around three percent of health care spending in the U.S. and about one percent of Medicare spending. Most of the rest is spent on chronic disease services. Medicare's "one-size-fits-all" benefit design is not set up to cover eye exams for individuals with diabetes, for example, or to reduce drug co-payments for those with specific diagnoses such as heart disease, AIDS, or depression.
The V-BID center's goal is to create a clinically nuanced benefit design that will encourage Medicare beneficiaries to increasingly use those services that improve patient-centered outcomes. In June, the U.S. House of Representatives passed a bill - which Fendrick helped draft - to allow more precise, clinically nuanced benefit design in the Medicare Advantage Program. "It's all part of changing the health care cost discussion from 'how much' to 'how well,'" he says.
"For the past few years, I've been involved in a fascinating discussion about a tobacco "endgame." Credit for the initial idea goes to Neal Benowitz and Jack Henningfield, who in 1994 proposed that the federal government mandate a reduction of the nicotine content of cigarettes to levels incapable of sustaining addiction. That proposal has since blossomed into the concept of a tobacco or smoking endgame - a knockout punch, if you will, to end the pandemic of smoking once and for all.
Wishful thinking? Perhaps. That hasn't stopped many of the world's tobacco-control scholars, strategists, and activists who share a common vision that the story of tobacco will conclude with two words: The end. Many of them met at SPH in 2012 to debate the merits of a tobacco endgame and to discuss the ways it might unfold.
Since the 1960s, smoking prevalence has declined by half or more in most developed nations - making tobacco control arguably the developed world's single greatest public health success story of the past half century. But it's not enough. The World Health Organization estimates that absent further progress, smoking will claim one billion lives in the current century - most of those in low-to-middle-income countries.
That's why we need a new approach. Despite the remarkable innovations of recent years - including smoke-free workplace laws, large graphic warnings on cigarette packages in dozens of countries, and plain packaging in Australia - the scourge of tobacco-produced disease is not likely to yield rapidly to current evidence-based interventions.
Among the endgame proposals now under discussion are the following: administrative mechanisms to remove the profit incentive from selling tobacco products, regulation requiring a reduction of nicotine in cigarettes to non-addicting levels, the imposition of a "sinking lid" on the supply of tobacco, a prohibition of the possession of tobacco products by all individuals born in or after the year 2000, and outright abolition of commercial tobacco product manufacture and sale.
These are bold, even radical, ideas. If they seem completely impractical, consider that just a little over ten years ago, no knowledgeable public health expert would have deemed it conceivable that in 2015 we would have 30 entire countries, and half the U.S. states, in which smoking is prohibited in every workplace, including all restaurants and bars."
- Kenneth Warner, Avedis Donabedian Distinguished University Professor of Public Health
With the income gap in the U.S. now higher than it's ever been - except just before the Great Depression - Lewis Morgenstern, a U-M professor specializing in health disparities research, is exploring ways the private sector can help reduce the gap. It's not just a question of economics, says Morgenstern, who has joint appointments in epidemiology and neurology emergency medicine and neurosurgery. It's a matter of health. "The more money you have, the more you can afford treatments and the less catastrophic it is if you have to miss work. You also have greater access to healthy foods and neighborhoods with places to exercise. Money really makes a difference."
Morgenstern's big idea is that employers can make it possible for employees above a certain income range to voluntarily contribute a portion of their income (say, one to two percent of gross salary) to fellow employees whose earnings fall below a particular income level.
He's quick to add that he's not talking about a salary increase, nor charity (he would not want see the program cut into charitable giving), but something closer to "leaving a tip for a restaurant server. Part of the expectation of being at the top end of the pay scale in a corporation should be the notion that you're going to give back to your work family." Funds would need to be distributed evenly and given anonymously, and other challenges resolved, but the fundamental idea "addresses the fact that wages have been incredibly stagnant except for people at the very top of the pay scale, and it deals with the tremendous income gap in all corporations." He's actively seeking companies to pilot the concept, as well as others who want to work on the idea.
James House believes President Obama's initiatives to improve the socioeconomic situation of disadvantaged groups may do more to improve population health and reduce health care spending than his landmark Affordable Care Act. In his new book, Beyond Obamacare: Life, Death and Social Policy, House, a research professor of epidemiology and the Angus Campbell Distinguished University Professor Emeritus of Survey Research, Public Policy and Sociology at U-M, argues that we are currently on the wrong track to solve the daunting - and paradoxical - problem of burgeoning health care spending but worsening population health. He advocates moving away from a supply-side approach that focuses on improving access to health care to a demand-side strategy that improves the main drivers of people's health - their conditions of life and work.
Over the past four decades, the U.S. has increased its spending on health care to a level 50 to 100 percent more than any other country. Yet over the same decades, life expectancy and infant mortality have worsened, relative to many developed countries and some developing ones as well, House says. That's because "we're not taking into account the role that social determinants and disparities play in driving both levels of population health and health care expenditures." Population health improves more by investing in creating healthful conditions of life and work than by spending more for health care, he says.
For example, "investments in early childhood education, better schools at the elementary and secondary levels, and better access to higher education have all been shown to pay off in terms of health outcomes."
House realizes his idea will be politically challenging. But he thinks the move to raise the minimum wage represents an important beginning. Politicians and corporate leaders "are starting to get the idea that if you pay better wages, you get better workers. If we also get healthier workers, we're saving more." House hopes his book will stimulate discussion about this fundamentally different way of approaching health policy. "It's very complicated and hard to change the health care system, so we need to look at what we can do differently."
- Julie Halpert