Making Health Care Reform Work

Abstract

PHYSICIANS AND BUSINESSES SHARE A COMMON goal—to advance better health. Employers are finding that it makes business sense to promote workforce health and productivity, recently linked to $576 billion in costs due to medical and pharmaceutical use, lost productivity, and wage replacement. Many mediumand large-sized employers, motivated by their self-insured status and by responsibility for much of these costs, are investing in an ever-expanding array of initiatives for fostering the good health of the healthy and health improvements for those who have or are at risk for disease or other impairment. In addition, the therapeutic value of work and its beneficial effects on health and wellbeing are becoming clearer to physicians. The longer people are off work, the lower their chances of returning to work. Evidence is mounting that links long periods of unemployment to poor mental and physical health and increased use of health services. Berwick acknowledged this growing alignment when he recently called for greater business involvement in health care reform. Business buy-in has often played a key role in the success or failure of major initiatives to reform US health care. For example, employer support has been pivotal to the evolution of the National Committee for Quality Assurance’s Healthcare Effectiveness Data Information Set (originally, the Health Plan Employer Data and Information Set) as the standard by which health plan performance is measured. Conversely, efforts to establish regional health information centers for clinical data exchange have largely stalled because employer support has been far short of expectations. Yet the business community maintains a low profile in health care reform under the Affordable Care Act (ACA), a development for which the business community bears some responsibility given its apparent, continuing decision to distance itself from the legislation. This is true even in those instances in which a higher business profile would strengthen the employers’ influence in better aligning reform with company objectives but also boost the sustainability of the changes being sought. Fortunately, the ACA’s emphasis on measurement, if broadened in a new direction, offers a path that will benefit both stakeholder groups in the current reform environment. This path should bring new empowerment to employers and thereby advance the staying power of ACA’s reforms. If well managed, it would also yield a major collateral benefit for physicians—better measures of the value of their care for the outcomes-oriented compensation schemes mandated by the ACA. Several examples illustrate missed opportunities for strengthening employer linkages vis-a-vis the ACA. For instance, accountable care organizations (ACOs) represent a major delivery reform that is now targeting both Medicare and commercial populations. With their buying power, businesses will heavily affect the long-term viability of many, if not most, commercially insured ACOs. Yet the ACA has no regulatory or incentive provisions for shaping the interface of business with ACOs and thus leaves largely untouched the capacity of businesses to influence ACOs in the marketplace. Another example involves ACA provisions for valuebased purchasing. Value-based purchasing consists of proven strategies that pay for care based on value, not volume, by rewarding physicians for more efficient and effective care. While advancing value-based purchasing on several fronts, the ACA overlooks a key extension for businesses. Fee-forservice remains by far the most prominent payment method for private sector health care. Appropriate tax incentives and rebates have much promise for accelerating businesses’ transition to value-based purchasing. However, the ACA contains no such provisions. A third example is the Patient-Centered Outcomes Research Institute. As the ACA’s entity for comparative effectiveness research, its focus includes quality of life, quality of care, and improved treatment adherence. Recent developments suggest that this focus is being expanded to consider the full range of evidence on direct and indirect benefits to society and patient differences in responses to treatment. This expansion only partially meets employer priorities. These priorities center on total health burden–both