Health care reform: The ‘new normal’ needs to go beyond clinical care

This is an extraordinarily difficult time to be a physician. As the leaders of state medical societies and board members of The Physicians Foundation, we represent primary care physicians and specialists across the country, in blue and red states. We’ve witnessed the Covid-19 crisis cost hundreds of thousands of lives and endanger many of our colleagues.

In the midst of this deadly pandemic, the U.S. health delivery system is facing its own economic instability. To an unprecedented degree, physician practices are on the brink of collapse, with patients staying home and telehealth reimbursements plagued by delays and other challenges. Hospitals, too, are teetering financially, laying off physicians or cutting their salaries.

And this is just the beginning.

Covid-19 is a multidimensional health crisis. In Louisiana, for example, five parishes account for 56% of Covid deaths (as of June 16) — and 78% of housing evictions. How can we ask our sick patients to shelter in place if they have no shelter?

In time, patients will return to their doctors’ offices and hospitals for routine checkups, deferred “elective” procedures, prescription refills, and more. But they will do so with their health compromised — even if they never had Covid-19 — presenting with diabetes, heart disease, mental health, and other conditions made worse by lost jobs and the struggle to afford food or rent. This will have a massive impact on physicians’ practices as they accept greater economic and physical risk and struggle with new practice challenges.

Over the past decade, state and federal governments, health insurance companies, health care delivery systems, and physicians have struggled over who should bear the cost when patients get sick. The Centers for Medicare and Medicaid Services and private insurance companies have increasingly shifted this risk to physicians, holding physicians responsible for patients’ health through quality measures and financial rewards and penalties.

The problem is that these measures, incentives, and risk models focus almost entirely on clinical care. Yet social and environmental factors, such as access to healthy food, safe housing, and other social determinants of health, drive 70% of health outcomes.

And that was before Covid-19. How does our notion of “risk” change when more than 36 million Americans have filed for unemployment benefits in the past three months and nearly one-quarter of U.S. households are reporting that “the food we bought just didn’t last, and we didn’t have money to get more”?

Millions of patients will show up in clinics exhibiting the physical toll of skipping meals to feed their children. They will have made impossible tradeoffs between refilling their heart medicine or buying food. They will carry the stress of spending weeks trying — and failing — to find a job as bills pile up and they fear losing their homes as the rent or mortgage goes unpaid and eviction bans get lifted.

The way that CMS and health plans quantify and allocate risk to physicians is simply irrelevant in the face of our country’s post-Covid-19 realities. It is clear that we cannot return to “normal.”

Now is time to do what we should have done long ago: make CMS and private insurers account for the realities of patients’ lives in risk models, quality measures, and financial incentives.

Health care providers capture their patients’ disease burdens and account for that risk through billing and diagnosis codes. Without these codes, a condition cannot be documented or factored into risk models that influence the type of care patients receive and how physicians get reimbursed. Nearly overnight, CMS implemented codes so it could pay physicians to diagnose and treat Covid-19 and account for the risk of complications.

If CMS can do this, surely it can do the same for patients living in a food desert or those who have recently been evicted. A patient with heart disease who is also food insecure costs $5,144 more per year to care for on average than a patient who is not food insecure. Right now, that risk and cost — which will only grow in Covid-19’s wake — is not factored into risk-adjusted payments to physicians. If it were, it could arm practices with the resources they need to hire staff or partner with others to connect patients to community resources, like healthy meal delivery programs or affordable housing.

We must also ensure that patients have access to quality health care and the basics they need to be healthy. CMS created the medical loss ratio (MLR) as an incentive for insurance companies to spend dollars on medical care — not on administrative costs — which is especially important now that so many physician practices are struggling to stay open and provide care for their patients.

At the same time, CMS must adjust the medical loss ratio to create incentives for health insurance plans to invest in the health of their members. Currently, if an insurer buys healthy food for a patient with diabetes, it counts as an administrative cost and the insurer is penalized — even though buying that food is good for patients and for their physicians, who bear the economic risk of managing their disease.

Before Covid-19, CMS proposed a new rule that would lift this penalty for Medicare Advantage plans, incentivizing them to invest in these “supplemental benefits” (like healthy meals or transportation to the grocery store) for their chronically ill members. By extending this rule to all insurance plans and members, CMS would reward insurers for investing in clinical care and unlocking additional dollars to help patients get and stay healthy, thereby avoiding huge costs to the health care system. States could do the same by activating their departments of insurance to make similar changes.

Covid-19 has caused enormous suffering for Americans while shaking the foundations of our health care delivery system. In the midst of all this, the Physicians Foundation sees a path forward to a better health care system — one that recognizes the realities of patients’ lives and rewards and invests in health. We cannot be afraid to seize this opportunity to improve health outcomes and our health care system.

Michael Darrouzet is the CEO of the Texas Medical Association. Jennifer Hanscom is the executive director and CEO of the Washington State Medical Association. Philip Schuh is the executive vice president and CFO of the Medical Society of the State of New York. All are board members of The Physicians Foundation.