Patients have multiple providers. These providers rarely interact. The payment system operates in silos. And patient care isn’t coordinated.
This disjointed system is not a new challenge. In 1965, the federal government created Medicare, a program which provides coverage for certain services. Medicare Part A covers inpatient hospital services. Medicare Part B covers outpatient care like physicians’ services.
Forty years later, in 2006, the government launched Medicare Part D, which covers prescription medications. But the original Medicare program created payment and data silos for Parts A and B. Today, Medicare Part D is administered by private pharmacy benefit managers (PBMs). And the three parts (Medicare A, B and D) rarely talk to each other or share information.
So, that’s the public sector.
The payment and health information silos, unfortunately, also exist in the private sector. Most of us are covered by some kind of health insurance which pays for physicians, hospitals, and diagnostic tests like x-rays or CT scans. But our dental plan is usually completely separate. And our pharmacy program is typically administered by a pharmacy benefit manager (PBM).
This fragmentation – both healthcare services and payment – leads to many patient care challenges and conflicts. Medicare Part D plan administrators (and PBMs) are laser-focused on keeping drug costs down. As a result, they may not cover certain medications. Part D plans (and PBMs) are not impacted by – nor really care about – increased hospitalizations or more diagnostic tests. That’s not their problem. They care about keeping drug costs low. They don’t care if their decision to limit coverage of some medications results in increased physician or ER visits.
But just when we take two steps forward, we take two steps back.
Medicare Advantage plans are privately managed and provide comprehensive services from hospital care to medical care to pharmacy and diagnostic tests. These plans are integrated to ensure proper care coordination. Medicare Advantage plans have incentives to provide the best care to the patient. These plans are the two steps forward I referred to earlier.
To help pay for ObamaCare, the president and Congress cut Medicare Advantage funding by more than $700 billion. Those are the backward steps.
The future of American healthcare is the promise of integrated systems where clinicians have access to patient data and payment models to reinforce coordinated care. Integrated systems do not create or reinforce silos of care. Integrated systems destroy silos. Patient care improves as a result.
Healthcare is just like everything else. More information is typically better than less.
You wouldn’t think about buying a car without the MPG or price or warranty information.
But in today’s non-integrated healthcare system, doctors don’t know what drugs other physicians have prescribed. Hospitals don’t know what tests and procedures have been performed on us as patients. And pharmacists don’t know if a patient has multiple prescriptions from multiple physicians for multiple controlled substances.
In integrated systems, more information is better. Physicians, pharmacists and other clinicians practice to the top of their licenses. Patients receive coordinated care that improves patient outcomes. And hopefully, because of health information technology, the American healthcare system can finally become a true “system” which drives and rewards performance, patient outcomes, and efficiency.
We need to break down more healthcare silos.