Who Will Fix the Healthcare System?

Everyone agrees that the healthcare system is broken. Whether you consider the number of uninsured in our country, the fact that health insurance premiums have risen much more than general inflation, or that, despite our country having the highest per capita expenditures, we have poorer overall health than other industrialized countries, the system is failing us. Some blame the system’s failings on the fee-for-service reimbursement system, which rewards volume rather than value. Others blame lack of planning, resulting in a system that responds not to need but to highly-reimbursed services. As a result, we have imaging centers on every corner. Still others blame the lack of any personal responsibility on the part of users for the ills of the system. The theory is that as long as insurance pays, the individual doesn’t care what it costs. No doubt all of these have contributed to the current condition of our healthcare system. The question now is who is responsible for fixing the system?

This question arose in the midst of a meeting of HealthRight, a coalition of providers, labor, and small business that is dedicated to achieving universal coverage for residents of Rhode Island and controlling costs. The group believes that this can be achieved by centralizing the purchasing of all healthcare through the Healthcare Exchange being implemented in our state. We all know that achieving these goals through the Exchange is a long shot. In the meantime, there are others, such as the largest insurer in Rhode Island, Blue Cross, feeling immense pressure from employers to reduce costs. Blue Cross, along with other insurers doing business here in RI, has been helped by guidelines issued by the Health Insurance Commissioner that limit the annual reimbursement increase Blue Cross can give hospital providers without seeking an exception. In a recent dispute with a hospital provider, Blue Cross cited these guidelines as a rationale for not granting the desired increase. The hospital mounted an aggressive and expensive public relations campaign. One member of the HealthRight group accused Blue Cross of “playing God” because the provider claimed that failure to achieve the requested increase would result in the hospital’s demise. There has been considerable debate within the state about how many hospital beds are required and there is probably some truth to whether this particular provider can survive, with or without the requested increase.

In my mind, this dispute just gives rise to the larger issue of who is responsible for fixing the system. In this case, the insurer is simply trying to control increasesin hospital costs, but insurers will be seeking bigger changes in the system, including global reimbursement (aka, capitation). Do the insurers have the right or the responsibility to drive the change? If not, who should? Will the providers reform the system on their own? (Unlikely!) Will the Legislature and Executive Branch mandate change through the establishment and implementation of clear policies, as seems to be happening in Vermont? (Most people are skeptical about the likelihood of all parties reaching a consensus!) Will the Exchange become strong enough to drive the change? (It’s too early to tell.) Will the newly established Comprehensive Health Planning Advisory Council take control and drive the change?

Some institution or body needs to take control if we are going to have a system that improves overall population health and makes healthcare affordable for all our citizens.

Who do you think should take the lead in fixing our broken healthcare system? As always, I welcome your comments. —Lou Giancola