WASHINGTON — More “dark data” about what works and what doesn’t in healthcare needs to be brought into the light, Austin Frakt, PhD, said here Wednesday at a health policy conference sponsored by America’s Health Insurance Plans.
“Only 0.1% of all spending in healthcare is on any evaluation of what we’re doing” — less than $1 billion out of the approximately $1 trillion spent annually on healthcare, said Frakt, director of the Partnered Evidence-Based Policy Resource Center at the VA Boston Healthcare System.
“And what is even harder than generating [that] evidence is paying attention to it,” he continued. “Even when we know when something doesn’t work, deinstitutionalizing it is hard; it can take years or decades to stop doing something that doesn’t work. [And] even though we have the data, it’s ‘dark data’ — it’s out there but we’re not seeing it and not paying attention to it.”
He gave the example of bone marrow transplants as a treatment for breast cancer. “This was touted as a way to rescue women who were treated with super-big doses of chemotherapy … It was considered so effective and worthwhile that it was required in some health insurance plans; this was all done before there was even a randomized clinical trial [of its effectiveness].”
Unfortunately, it was several years before a trial showed that the regimen was ineffective, Frakt said, and it eventually came out of clinical practice “but not before many, many women were harmed, and that is because we moved forward with coverage for a treatment that wasn’t effective and was actually harmful.”
Of course, “there’s nothing wrong with spending, especially on something that’s valuable … but there’s a lot wrong with spending on things that aren’t valuable,” he said.
Although the U.S. healthcare system is now one of the most expensive in the world, that wasn’t always the case, Frakt noted. So what happened? If spending is seen as healthcare prices multiplied by quantity, both have gone up over time, he said.
As for the quantity of services used, the U.S. is on the lower end compared to other countries when it comes to doctor visits per capita, for example; the same is true with numbers for hospital visits and hip replacements and most other procedures, except for knee replacements, he said. “So if it’s not quantity, it’s prices.”
Brand-name drug prices are also much higher in the U.S. than elsewhere, as are the prices for certain procedures like MRIs, cardiac catheterizations, and angioplasty. So then the question becomes, “If we believe not all the additional spending is worth it … What do we do?” he said.
One option is radical reform, such as instituting a “Medicare for All” reimbursement system. “I’m not going to say a lot about this because I don’t think it’s going to happen,” said Frakt.
Changing the “demand side” of healthcare through the use of increased cost-sharing and more price transparency is another option, he continued. “Increased cost-sharing definitely decreases what we spend on healthcare through utilization reductions. The downside is that it puts the decision-making in the hands of patients in terms of [whether a particular service] is worth the price. Patients don’t know the answer; they cut back indiscriminately” on both useful care and wasteful care.
Price transparency is a relatively new idea and is becoming more visible, Frakt said. However, “to date, in the ways we’ve tried to do it, it isn’t very effective. Very few people take advantage of price information.”
Decreasing the supply of healthcare by using global budgets and rate-setting is another possibility; however, it puts the onus on providers. “That’s a little more of an intervention and we don’t see [a lot of] global budgets these days … More [often] it’s bonuses and quality measurement,” he said.
Finally, there is increasing competition. “There is a lot of evidence that prices are higher when competition is lower,” Frakt said.
On the whole, “When you factor in the political realities, the way to manage the healthcare system is not through ‘Medicare for All’ — I don’t think that’s likely or realistic,” he concluded. “Instead, we’ll need dozens of small improvements, long-term over time. It’s going to be a long-term management issue.”
“Medicare for All” also came up during a luncheon address by Rep. Frank Pallone, Jr. (D-N.J.), chairman of the House Energy & Commerce Committee, who seemed to tamp down the possibility that such a large system transformation could occur in the current political environment. “When people voted for a Democratic [House] majority in November, they were basically voting for a check on the president,” he said. “I keep reminding everyone that if all I do over the next 2 years is stop the bad things Trump does from happening, I would have accomplished a lot.”
Stabilizing the Affordable Care Act (ACA) and stopping the White House’s efforts to “sabotage” the law would be on that list, he said, adding that Congress will also look at longer-term solutions, like allowing people under age 65 to buy into the Medicare program. However, “the likelihood they will become law with a divided Congress and Trump as president are practically nil. The focus has to be on the things we can do.”
Pallone announced one action the committee took on Wednesday: launching an investigation into the marketing practices of nine insurers and three brokers who are selling short-term limited duration insurance policies. “I’m particularly concerned about whether these plans comply with protections of the ACA,” Pallone said. “Some people are selling ‘junk plans’ that have marketing tactics that mislead patients about the services they’re providing. We’re going to investigate these plans, investigate their marketing practices, and hold them accountable.”