Policy Must Be All About People, Patients, & Populations. Is It?

By Suresh Kumar

Healthcare policy conversations are abstract, esoteric, or mind-numbing. They confuse, rather than clarify, and scare the vulnerable and the frail. A panel of medical professionals establishing coverage covenants was made out to be a “death panel” a few years ago. Today’s aspiration for universal healthcare is confused with a single-payment system and framed as the government taking over your health. Playing politics with policy misguides populations and protects unsustainable, unaffordable, and inefficient practices.

In our hybrid healthcare system, over two-thirds of Americans have private health insurance. Fifty-five percent of us are covered by employer-based insurance that many loath to trade in for government-run plans. Over another third of Americans have public health insurance (government plans). Whether they have private or public insurance, most Americans are satisfied with their healthcare; but they are unhappy with how much it costs and scared by the sustainability of ever-increasing drug prices, health insurance premiums, hospital costs, and out-of-pocket expenses. Experts are unhappy with healthcare costs, too. They are also unhappy with health outcomes and poor return on healthcare investment in the U.S. Partisan rancor and unpredictable policies have resulted in low trust in the current administration, which, when compounded by fear of the unknown, causes reticent citizens to trade one health plan for another, or explore newer, more sustainable health coverage and insurance models.

Viewing healthcare through the consumer or patient lens humanizes policy, making it more relevant to the times and to our unique demographics. Doing so will help address:

1. Who and what services are covered.

2. How much of the cost is covered.

3. How this will be paid for.

Case illustrations from different demographic groups illustrate needs and humanize health-policy considerations.

PREVENTION AND PREEMPTION: THROUGH CONCEPTION TO ADOLESCENT YEARS

Sixteen-year-old Helen Obanado suffers from sickle cell disease, which is debilitating to the patient, emotionally exhausting to parents, and economically draining to both parents and the healthcare system. Current treatments include bone marrow transplants or regular monthly blood transfusions that cost around $100K per year, but now new technologies hold exciting possibilities for curing the disease. These therapies range from genetically modifying immature red blood corpuscles removed from bone marrow and infusing them back into the patient’s blood stream, to gene-editing. Helen is one of the fortunate few to have undergone experimental treatment, and is now the youngest person with a DNA reset. She has her life back. Today, there is hope for patients like Helen. While patients are cured one at a time, care becomes affordable and populations become healthier when access to care is available to all who need it. How do we graduate from the roulette of “wondering who will be lucky enough to qualify for innovative treatments” to developing the financial incentives and pricing mechanisms to commercialize and scale new technologies that prevent or cure disease?

Premarital screening can inform couples of congenital issues and errant genes, if the couple plans to have children. Armed with that information, those couples choosing not to move forward prevent disease and save themselves cost and anguish. Those who decide to move forward are forewarned of the need for subsequent genetic testing to identify a single embryo free of sickle cell disease to preempt and reduce the incidence of disease. Screening newborns helps early identification and treatment. All three pathways result in healthier populations and lower lifetime cost of care.

SUSTAINABLE CARE MODELS TO PROTECT WORKING AMERICANS AGAINST CATASTROPHE: 18-64 YEARS

Jim is a 52-year-old who worked as a manager in an engineering company. He was single, financially independent, and physically fit, with healthcare coverage through his employer. But a car accident has left him paralyzed and with brain injuries. The accident case is unlikely to be resolved soon, and it is unclear whether he will get any compensation. Jim has spent most of last year in hospitals and nursing homes, and it is unlikely that he will be able to go back to work. He requires constant supervision and specialized care. His progress appears to have plateaued, hospitals will no longer keep him, and doctors remain noncommittal regarding if, when, and to what extent Jim will recover. It is likely he will require assisted care for a long time.

Jim’s employment will be terminated soon, and his employer-sponsored short-term disability and medical insurance will run out. His sibling intends to sign him up for COBRA, for which Jim will pay the entire premium instead of an employer paying some. He will have to buy further insurance on the exchange to plug coverage gaps. Thereafter, Jim’s only recourse will be to draw down his assets to pay for healthcare until he becomes eligible for Medicaid and gets nursing home care. Jim confronts a policy abyss and economic ruin. This is not what America is supposed to be.

Neither private nor public insurance provides Jim affordable, workable solutions. Long-term care premiums are too expensive for most people, Medicare does not provide such care, and Medicaid, which does, covers nursing home care, but may not cover home healthcare and specific providers. Shouldn’t cheaper, patient-preferred, community-based care alternatives to nursing homes be covered? Nobody aspires to poverty, or health-catastrophe-prompted bankruptcy, but until Jim’s modified gross income is below the state-established poverty threshold, he has no access to sustainable care. Should America require people to hurtle down the road to poverty to secure healthcare? Shouldn’t Jim and his family have a say in what is covered and what is not? People with disability, the elderly, and those requiring long-term care fare better in familiar settings — at home and in the community, amongst friends and family — than at more expensive nursing homes or care facilities.

ENCOURAGING AN AGING POPULATION TO STAY PRODUCTIVE

In an aging America, children are often caring for their parents. Sixty-five-year-old Leticia is the principal caregiver for her mother Destiny, 81. She is hardworking and prides herself on paying her own bills. Leticia makes $30,000 annually working two jobs. But admirable work ethics, long hours, and constant berating from her mother about not caring enough are taking a toll. Stressed, Leticia lives in constant fear of the next call from her mother summoning immediate attention that could trigger her employers to fire her. The caregiving daughter herself needs some TLC.

Shouldn’t a healthy society encourage people to be independent for a longer time? Coverage for a community-based caregiver to remotely monitor Destiny’s movements and vital statistics will help identify urgent needs, and twice-daily 30-minute home visits to assist Destiny with basic needs and companionship will keep her physically and mentally healthy. It also will provide Leticia a guilt-free, productive employment.

HEALTHCARE COVERAGE MUST EVOLVE WITH THE NEEDS OF SOCIETY

Comprehensive healthcare policy must address the needs of adolescents, working Americans, and the elderly. It must provide timely, high-quality delivery of acute and chronic care, while also protecting against infectious disease. To be humane, policy must address prevention, dealing with catastrophic health events, and keeping populations happier and more productive. For the business of healthcare to succeed, healthcare delivery must be more meaningful. For example:

• Prevention is the best cure — inventive models to accelerate access to new technologies and therapies that prevent and cure disease will reduce healthcare costs.
• Cure is next — new business models must go beyond keeping people out of the hospital and chronically ill patients on medications in perpetuity, to weaning people off drugs.
• Maintaining a healthier, happier, and more active population that stays at home longer is also important. Community-based care is a substitute for more expensive nursing home care. It also can provide retraining and stable higher-paid employment to people likely to be displaced by automation and technology (e.g., those in retail, taxi and ride-sharing services, and trucking).

Financing mechanisms that scale pay-for-outcome models and develop a healthcare futures market for our most enduring asset — health — to help spread costs over time (as we do for real estate) will be necessary to deliver the benefits of innovation and new care models.

SURESH KUMAR serves on the board of Jubilant Pharmaceuticals and Medocity. Formerly, he was U.S. Assistant Secretary of Commerce and executive VP at Sanofi.