Cantrell Corner: Bringing Accuracy to the Public Discourse on Health Care

Topic(s):

Legislation & Regulation , Medicaid

With the new year in full swing, I’ve been thinking a lot about what the next 12 months will bring. At AMCP, there is a lot we are aspiring to do. But one thing that I hope all of us in managed care pharmacy—and the health care community—can help bring is greater accuracy to our public discourse about health care in our country. When it comes to health care, emotions understandably can run high. As the CEO of an organization whose members are dedicated to ensuring affordable access to prescription medications for patients, I know that our diverse membership holds many strong yet well-reasoned perspectives. But I’m worried about the state of the conversation concerning health care in our country. All too often, it’s not just mean-spirited; it’s deeply inaccurate, often jumping to caricatures about health insurance. Health care professionals of all walks of life have an obligation to call out incorrect information or misunderstanding—to take tangible steps to restore greater nuance and understanding to the discussion.

The American health care system is a force for innovative treatments that have bettered countless lives, but it has become remarkably complex and expensive. There is frustration and anger at the system. That was evident following the heinous murder of UnitedHealthcare CEO Brian Thompson.

There rightly has been an outpouring of sympathy for his family, colleagues, and friends and general disgust at this violence. However, this empathy was lacking in many corners of the internet; online reactions mocked Thompson’s death, facetiously referencing preexisting conditions and prior authorization.

In addition to this concerning callousness, the response reflects a lack of understanding when it comes to complex health care concepts. For example, some posted comments about denial of coverage due to preexisting conditions, which has not been a problem since the passage of the Affordable Care Act.

And then there’s prior authorization; it often frustrates many patients, and there are certainly areas to improve and streamline. But its purpose is not to make money at the expense of patients. It is a tool to protect patients and encourage cost-effective care, existing to facilitate the use of therapies and medications that evidence has shown are both effective and safe. For example, when opioids are prescribed, prior authorization can be an important safeguard to help ensure their appropriate use.

In fact, we recently saw another example of how widespread misperception can negatively affect a conversation about health care: the controversy over Anthem Blue Cross Blue Shield’s policy on anesthesia services. Anthem recently announced an update to its policies that would have adopted a maximum amount of reimbursable time for procedures and required justification for longer times—an approach drawn from the Centers for Medicare and Medicaid Services Physician Work Time values.

The updated policy was intended to protect patient finances by reducing overbilling and upcoding, when physicians or hospitals report more expensive or greater amounts of care than actually provided. This practice is all too common in the health care industry.

Crucially, Anthem’s updated policy would not have increased patients’ costs. Hospitals and providers are prohibited from billing patients for the difference between the claim amount and the reimbursement rate.

However, Anthem quickly reversed course because of a misunderstanding of what the shift actually meant for patients. Following an announcement by the American Society of Anesthesiologists about the change— “another example of insurers putting profits over patients”—the discussion spun out of control. Instead of a sober conversation about how costs would shift from insurers to the doctors, we witnessed public outrage and arrived at a result that won’t make care more accessible and affordable for patients. 

So, what can we do about this? There’s no quick fix, but the health care community can help improve the situation in several ways. First, we must do a better job of educating the public who can find our processes complex and our rationale opaque. It starts with working to identify patient voice and taking steps to make sure that it guides not just our work, but how we talk about it.

For example, payers should think about how to better reach their customers when explaining their benefits and their rights—things such as how to appeal a denial or request a coding review. Better understanding and transparency about options would go a long way.

Next, trusted sources of insight—particularly health care associations—need to talk about complex health care issues in a responsible manner. All of us have to stop the histrionics and scapegoating when the answer lies in dialogue. Providers and payers have an obligation to work together to make health care more accessible and affordable for patients. As we saw in the Anthem episode, how we frame a conversation early on can play a major role in whether it takes a constructive direction or instead is derailed through misperception.

Finally, we need to err on the side of evidence when talking about contentious issues. Take the debate about pharmacy benefit managers (PBMs) as an example. PBMs have been cast as entirely responsible for high prescription prices, with criticism often focused on their “middleman” status.

But the reality is far more complicated. PBMs don’t set list prices for pharmaceuticals; they negotiate price reductions with drug manufacturers. They also play a key role in encouraging appropriate care and identifying waste and fraud. Unfortunately, many of the proposals to broadly regulate PBMs (such as banning spread pricing entirely) would have an adverse effect, either removing incentives for PBMs to pursue lower prices or unduly restricting how they balance patient safety and costs. Rather than rhetoric, our policies need to be grounded in sober evidence.

Overall, the current state of conversation isn’t making things better. For all health care professionals, it’s time to tackle the misunderstanding in our health care debate and focus on real solutions for patients.