Issue Brief: “Game Changers” Moving Health Care Reform Beyond Coverage and Payment  

For many years, discussions of health care reform in the United States basically came down to two issues: expanding access to health care services (coverage) and changing who, how, and how much we pay for it (payment). The current debate is built on additional dimensions: improving the quality and coordination of health care, as well as measures that over the long term should improve both the effectiveness and efficiency of health care delivery and decision-making.  

The Obama administration has proposed that in this round, building on a set of “game changers” will result in a different kind of debate as policymakers, providers, and patients come to think differently about health and how health care is provided and consumed in America. Importantly, efforts to provide a foundation for most of these game changers already are under way.  

  1. Health Information Technology – Using information technology to improve the quality and efficiency of health care and to provide oversight over public health and health care delivery. Patients’ health care records often are scattered across their providers, making it difficult to coordinate care and avoid duplicating tests and treatments when the patient does not remember, or has not requested that previous records be sent in advance of a physician visit. Because the resulting delay may be medically inappropriate as well as inconvenient for the patient and wasteful of the provider’s time, it is not unusual for duplicative procedures to be ordered. Ultimately electronic health records (EHRs) that allow physicians, hospitals, and health insurers appropriately to share information, could enable patients to receive care in a safer, more timely, and coordinated manner while avoiding needless delay and duplication. Analyses of data gathered from EHRs (and that does not identify specific patients) also could help improve outcomes, as well as help timely identify and combat risks to public health.  
  1. Comparative Effectiveness Research – The conduct and synthesis of systematic research comparing different interventions and strategies to prevent, diagnose, treat and monitor health conditions. The purpose of comparative effectiveness research is to inform patients, providers, and decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances. The Federal Coordinating Council for Comparative Effectiveness Research has said that “to provide this information, comparative effectiveness research must assess a comprehensive array of health-related outcomes for diverse patient populations. Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, behavioral change strategies, and delivery system interventions. This research necessitates the development, expansion, and use of a variety of data sources and methods to assess comparative effectiveness.” [Click here to view draft definition.] Increased investment in appropriate and methodologically sound research on comparative effectiveness could provide physicians and patients with the information they need to make more informed health care choices.  
  1. Prevention and Wellness – Expanding access to preventive care and helping patients live healthier lives. At present, much of the U.S. system of health benefits is limited to coverage and payment for the treatment of illness or injury once the patient seeks help. However, much of the rising cost of health care is driven by treatment of late stage consequences of untreated chronic conditions. Many believe that our health care system needs to provide incentives for better screening, prevention and early intervention. Health care that provides patients with the knowledge and incentives to stay healthy can improve the quality of patients’ lives as well as reduce the incidence of more serious illnesses that require costly forms of treatment.  
  1. Improving Quality – Reducing health care disparities and improving outcomes through the use of consensus-based standards for improving safety, care coordination, and continuous improvement in health care delivery. Processes for developing standards and increasing the availability of useful information are well under way. The question is how best to motivate consumers, providers and health plans to ensure that their decisions and practices implement these standards. In the context of health care reform, some are calling for realigning incentives so that physicians and hospitals are encouraged to take the time needed to provide coordination and preventive support to patients with complex needs and chronic conditions. Some are concerned that too much of health care delivery is paid for on “piece rate” for specific procedures or episodes of care.  

Why are they “Game Changers”  

None of these ideas is new. Moreover, the groundwork for implementing significant new initiatives in these areas has been laid in recent health legislation. For example, the American Recovery and Reinvestment Act (ARRA) included incentives to physicians and hospitals to adopt and use EHRs, provided $1.1 billion for comparative effectiveness research, and established a Federal Coordinating Council for Comparative Effectiveness research. The Medicare Improvements for Patients and Providers Act of 2008 gave Medicare new authority to cover preventive services. And since 2003, several laws have created programs that have linked Medicare payments to the submission of quality data.  

What is new is the heightened emphasis on these four pillars as a foundation for overall reform of the health care delivery system. They are included in President Obama’s principles for health reform, the Senate Finance Committee’s descriptions of policy options, and to varying degrees, the health reform legislation packages introduced this year. According to Peter Orszag, Director of the White House Office of Management and Budget, these four measures are crucial to improving the quality and efficiency of the health care system and must be pursued even if they are unlikely to produce savings in the short term [Click here to read Peter Orszag’s blog letter]. In fact, many of these measures will require additional spending in the near future.

Although lawmakers and stakeholders disagree about details, and each of these four raises significant and major policy considerations in its own right, there is a growing consensus that health reform must not be the same old game of your coverage expansion vs. my payment reform. To the extent that lawmakers remain focused in building reform on these “game changers,” they could be as important in reshaping Americans’ health and health care as the much-debated policy options relating to insurance, taxes, and government programs.