An Insurance Thought Leadership Exclusive
In recent weeks much has been said about contraceptive coverage and whether or not President Obama should have done what he did. As a result of that, many are wondering whether or not other decisions will be made by this special government-formed task force that is part of health care reform. Is this something else that we should fear? Is there value in it? Why or why not?
First of all, I must offer this caveat: I am presenting my own personal opinions, not that of my company, and not necessarily that of my profession or other associations I am part of. This is a controversial topic and it is likely that some readers will disagree with my comments. I accept that and would like to share my opinion, perhaps adding some light on the topic.
Perhaps a look back might be helpful in understanding the situation or health care system as it stands today. Today, who determines whether or not a service is beneficial to a patient? Most of the time, this is determined by the physician or provider delivering the service. We, as patients, select a provider we trust, and listen to what they recommend to us, perhaps supplement that with a visit to WebMD.com or its equivalent, perhaps ask a friend or relative, but generally listen to our doctor and do what he says. Who is to say that our provider is right? For many years we didn't question this, and if we did we would find a new provider who we did trust.
The reality of the situation is that in many situations our provider might not be making the best choice on our behalf. First of all, there is somewhat of a financial conflict of interest. If they provide the service, they benefit financially. If they don't, they are paid less. Will the decision be impacted by the financial outcome? Secondly, providers are heavily impacted by their current practice style, their training and what they are familiar with. Studies show that practice patterns vary between various markets, and even within a single market. What makes sense to one provider doesn't to another. What is the norm in one city can vary significantly from that in another. What makes sense to one specialty may conflict with another specialty. Today we really don't have any single authority that we can rely on and trust. So by default we listen to those we trust who might not be as trustworthy as we think and believe.
Realizing the potential for different opinions and the lack of a trusted source, individuals and organizations began a concerted effort to try to define what is right and wrong. Company A started to build its set of criteria or practice guidelines while Company B developed theirs. Provider Specialty C developed theirs, while Provider Specialty D pursued another path. Individual health plans developed their own or licensed one or more sets from various vendors and other sources. The government even established a clearinghouse (i.e., Agency for Healthcare Research Quality) to monitor and keep track of various guidelines. The proprietary ones were copyrighted, oftentimes requiring substantial license fees to use. Others were made available to all at no cost.
Through this effort a concept called “Evidence Based Medicine” emerged which described a process where the best literature and evidence available was used to develop the guidelines. Through this process, evidence is graded (i.e., from most reliable to least reliable) with specific information synthesized and guidelines produced. Some guidelines were built around a desire to maximize efficiency and control costs, others where focused in other areas. The significant effort has resulted in very valuable information from competing sources, potentially with differing opinions. This source of information provides the provider community additional information for it to make a decision; however, some will not have access to all of the information for a variety of reasons noted above.
The Big Dilemma
So we are now faced with a big dilemma. If we leave it up to individual physicians to make the choice for treatment, we are faced with significant personal bias, perhaps with some limitations in a valid rationale to make the necessary choices. If we rely on the vast guideline options and choices, we have more useful information to help make the choice but are faced with what do we use, how do we use it, and what should we use. Who is going to sort through the information to help assure us the right choices are being made? Can we rely on the provider to do this? Do we rely on the health plan? Can we rely on the internet? Today there is no real source such as the “Good Housekeeping Seal of Approval” for health care guidelines to tell us what is the right answer. What do we do?
A Surprise Solution
Buried in health care reform legislation is an interesting group called the United States Preventive Services Task Force. The primary purpose of this group is to make the decisions we talk about above. To keep the government out of the decision making process, this committee is somewhat independent of regulation by the government. The members of this panel are charged with making good decisions. The use of a national body will maximize the likelihood that this can become the standard. It won't be biased from a health plan's profit motive. It won't be biased by the financial bias of our personal provider. It will rely on the best information available to make the right choice. It will include an important emerging area called Comparative Effectiveness where emerging technologies can be compared to determine what works the best.
It isn't designed to prevent us from having something done we would like to have done, but if not on the list, we might have to pay from our own pocket. It will become the standard of reasonableness. It isn't something to be feared as long as it can remain somewhat independent and focused on pursuing the right answers. Periodically I am pleased to find government-developed, valuable solutions to concerns I have about the health care system (e.g., RBRVS relative values for pricing of physician services, risk scoring, etc.). This Task Force is another one of these in my professional opinion. This may be hard to believe to some who have limited trust in what the government has done or is doing.
As long as the politicians let this task force operate as it was intended and recruit the best people to serve on it, I am confident that all Americans will benefit. The big problem is that it looks like another attempt by government to control our lives. I prefer describing it as an attempt by the government to protect us from bad decisions by ourselves and those we try to trust, our health care providers. I come down on the side of applauding this effort, not criticizing it.