by Joyce Frieden
News Editor, MedPage Today
The industry 'is so screwed up and it's ripe to be disrupted,' says David Feinberg, MD, the CEO and president of Pennlyvania-based Geisinger Health System.
WASHINGTON – The U.S. healthcare industry could use a good shaking up, a healthcare executive said here Tuesday.
"I think our industry is so screwed up and it's ripe to be disrupted," David Feinberg, MD, MBA, president and CEO of Geisinger Health System in Danville, Pa., said at a conference sponsored by the Duke Margolis Center for Health Policy and the consulting firm McKinsey & Co. "Either we do it or some Stanford dropout in a black turtleneck is going to."
"Can we take care of people in a way that's dignified, that's culturally sensitive?" he asked. "Can they afford it? Is it easy to get? Is it something you want for your own family? Let's focus on high value, great experience, and low costs."
On the other hand, many of the problems with the healthcare system today are really public health problems and aren't something that private insurers can readily fix, said J. Mario Molina, MD, president and CEO of Molina Healthcare, a managed healthcare company based in Long Beach, Calif. "Obesity is not something you're going to cure; it's a public health issue. ... We really can't expect health plans to [take care of] that."
"We try to do something about obesity, but it's really difficult from a health plan, medical model," he continued. "We're really good at covering acute illnesses or managing chronic ones [but for conditions like obesity] it doesn't work well. We need to invest more in public health; if we did that, we wouldn't invest as much in healthcare per se."
But Feinberg disagreed: For example, "We take diabetics who are food insecure and say, 'Here's food for the whole week for you and your family' -- every week. We've seen decreases in hemoglobin A1c in every single patient, decreases in weight, decreases in blood pressure ... if this was a pill it would be a miraculous pill. We've had patients we had spent $220,000 in 4 years before we started giving them food; in the year they've been in the program, our medical cost is $1,200. Hippocrates talked about food as medicine a long time ago; I think we've lost our way."
Sometimes solving healthcare problems calls for breaking the rules, he continued. "When I got to Geisinger a couple of years ago, there were providers we were spending $500,000 a year on for visits, and the only thing they did was prescribe opiates. They weren't even in our network." But when Feinberg wanted to stop using them as providers, he was told he couldn't cut them off without going through a laborious process to do so.
But "they were [essentially] giving bullets to our patients," he continued. "I said, 'Cut them off and send the regulators to me.' The regulators came to me and I said, 'Put me in jail. I got rid of five doctors who only prescribe opioids to patients' ... We say, 'Let's do the right thing and let the chips fall where they fall.'"
The Affordable Care Act's health insurance exchanges also came up at the meeting. "The vast majority of [state health insurance exchanges] are stable and working well," said Peter Lee, executive director of Covered California, that state's health insurance exchange. "For 30% that's not the case, and those markets are at risk of destabilization. It's very important [to understand] that we're not talking about a ship that's sinking."
One thing that could destabilize the exchanges, however, is if the Trump administration takes away the cost-sharing reduction subsidies that the federal government is giving to states to help low-income enrollees pay their out-of-pocket costs. "If you don't [keep the subsidies] ... it's going to cause massive disruption," Lee said.
But the bigger danger for stability is non-enforcement of the penalty for not buying health insurance if you can afford it, he continued. "Until there's an effective replacement, non-enforcement of the penalty would lead to mammoth increases in premiums and huge reductions in coverage."
In addition, money must be invested in marketing the exchanges, Lee said. "Health insurance has to be sold. Covered California spent $130 million this year to promote enrollment and outreach. ... If you're not investing in marketing, you're going to get a bad risk [pool]" because only the sicker patients will be incentivized to sign up for coverage.
Dennis Matheis, president of the Central Region and Exchange at Anthem, a for-profit health insurer based in Indianapolis, Ind., listed several ideas proposed by Republicans which he said would encourage insurers to stay in the exchanges. Allowing insurers to charge older people up to five times more than younger people -- rather than three times higher, as is the case under current law -- "will help improve affordability for younger people in the marketplace," he said. And re-establishing a mechanism for re-insuring the health insurance companies for high-cost patients "will help stabilize the market."
But Lee said he wasn't sure if changing the rating bands would really make a difference. "It's unclear if that will help, because it dissuades, older, healthier people from signing up." And getting more younger people to sign up for health insurance even though they typically buy cheaper, less comprehensive plans "is not lowering costs -- it's changing who pays the costs and saying that more should be paid directly by consumers. That's a formula for more bankruptcy and not necessarily better care."
When it comes to improving public healthcare programs, such as Medicaid, "block grants are a lousy idea," said Sen. Bill Cassidy, MD (R-La.). "If you just [make block grants] based on what the state has [already] received, then those states that have gamed the system are rewarded and those who have not gamed it so much are penalized." Per-capita caps, which take into account a state's changing demographics, are a better way to go, he said.