Gilfillan: U.S. must change private marketplace to move to ‘patient-centric’ approach

Brian Smith | Staff PhotographerRichard Gilfillan, former head of the Center for Medicare & Medicaid Innovation, delivers Wednesday’s morning lecture in the Amphitheater.
Brian Smith | Staff Photographer
Richard Gilfillan, former head of the Center for Medicare & Medicaid Innovation, delivers Wednesday’s morning lecture in the Amphitheater.

Dr. Richard Gilfillan thinks that basically every health professional has walked a career path paved with good intentions. No one who has stepped up to the podium this week in the Amphitheater, the Hall of Philosophy or anywhere else on the grounds hates the idea of making people healthy.

“No one comes here and says they want to provide fragmented health care at an unreasonable cost,” he said.

In his morning lecture at 10:45 a.m. Wednesday in the Amp, Gilfillan said this belief has contributed to “incredible optimism” for the future of American health care. He spoke about the pros of the Affordable Care Act (ACA) and the steps the country has to take moving forward. Gilfillan spent much of his career in the private health insurance sector before becoming director of the Center for Medicare & Medicaid Innovation, a position he held from 2010 until this past June.

Gilfillan started and ended his lecture referencing philosopher John Rawls. Gilfillan drew on Rawls’ “original position” thought experiment to explain why he believes society should guarantee that everybody have access to sufficient health care. In Rawls’ thought experiment, one imagines he or she is about to be born into a society without knowing what talents, abilities, socioeconomic status, ethnicity or gender he or she will have. One has to decide from behind this “veil of ignorance,” as Rawls calls it, what principles should guide the society he or she is about to join.

“Would you possibly create a system that leaves out 20 percent?” he asked, referencing the portion of the United States population that didn’t have health insurance before the ACA.

For him, the answer is no, so he’s glad the ACA has started shaping American society into what he visualized in the thought experiment.

He praised the advances the ACA has made toward universal health care. Before its passage, approximately 55 million Americans did not have health insurance. Once the act’s provisions come into effect, that number will move closer to 25 million to 30 million people, as estimated by the Congressional Budget Office. This increase is due to the expansion of Medicaid, the fact that people can now remain on their parents’ health insurance plans until age 27, the inability of providers to deny coverage because of a pre-existing condition and the soon-to-be-implemented insurance exchanges, Gilfillan said.

“It’s a big step in the right direction,” he said.

But the ACA can’t be the only step if the goal is a universal, “patient-centric” health care system, he said. The current framework of the American health care system is not sufficiently outcomes-based — it doesn’t focus enough on whether or not a provider gives quality health care. He said the United States’ system lacks a sufficient accountability mechanism.

He compared the current health care system to a restaurant that does not show prices on its menu. If customers don’t know the price of what they’re buying, they may end up being overcharged. If that happens at a restaurant, though, it’s relatively easy to call up and complain, either to the restaurant directly or to an organization like the Better Business Bureau.

“But if it’s the health care system, there’s no one to call,” Gilfillan said. “There’s no one accountable for the outcome.”

In terms of health care and insurance, when the currency of the day is, well, currency — when board meetings center more around the fiscal bottom line than they do on the quality of the care — the system is asking for trouble, Gilfillan said. He said that even people with good intentions — referencing his earlier point about those in the health care industry — often end up acting in less-than-savory ways. The insurance companies he worked for weren’t strangers to denying coverage and charging high prices.

“We did not want to do that,” he said. “But we did.”

He said his companies, like so many others, had to make tough choices when faced with their immediate business realities. Business models drive outcomes, he said. The private sector behaves the way its marketplace dictates and requires; if Americans want the private insurance sector to change, America has to change the economic geography of the sector’s marketplace.

“The marketplace has to deliver the goods,” Gilfillan said. “Insurers, providers — they have to deliver the goods; the federal government is not going to. But we can and have and will continue, I’m sure, structuring a market where the participants in the marketplace deliver these results.”


Q: Could you talk a little bit about the requirements — what some people would call burdens — that the [Affordable Care Act] places on private employers in terms of insurance coverage?

A: Yeah, well, I’ve spent most of my time on the provider side, delivery system side. I’m happy to try and give you some thoughts. I can’t claim to be definitive here, but I think the major thing here is the requirement for employers [that employ more than 50 people] to provide coverage. Now the truth is that the vast majority of those employers already were providing coverage, and generally the impact of that was relatively small in terms of the employer base as a whole. And recently there’s been a decision to kind of hold on that mandate for a year as everybody gets the wherewithal, if you will, to administer their programs under these new requirements. So I think that’s the major initiative that folks raised concerns about and, in fact, it’s a relatively small piece of the overall increase in coverage that is expected.

Q: Given the amount of opposition that exists in Congress and across the country, can you talk a little further about why you’re as optimistic as you are?

A: Sure. There are lots of reasons for the opposition, and I will leave to the more seasoned political commentators to get at a lot of that. But the reality is that we already have people like Kelsey [Burritt] attaining health care insurance and almost a million folks getting coverage because of the expansion of the 26. We’re going to very shortly have open enrollment, during which folks who’ve never had access to health care before are going to have access. They’re going to receive support in sub-cities, and I think we’re going to see a building constituency supporting the overall program rather than criticizing it. And I think we’ve already seen some of that. It’s iffy, and we’ll get through this next phase, I think, with ultimately a growing positive wave of support, and there are the practical realities of the Congress and what it would take to change the law, of course would ultimately require a majority from the Senate and the House — or actually a super majority in the Senate — and then something assigned by the president. I don’t think we see that in the next three years, and I think we will see much more explicit experience with the results of the Affordable Care Act and much more support over these next couple of years.

Q: Why isn’t the compensation of primary care doctors being addressed by the health care industry or Obamacare?

A: Oh, it is, very directly. We increased payments for primary care docs directly through the Affordable Care Act. We provide additional payment for primary care, care management fees, and we’re testing those new payment approaches right now in several initiatives. Through the initiative, the [Center for Medicare & Medicaid Innovation]’s most recent guidance document asks for comments about whether to add care management fees directly for primary care doctors in 2015. So it is being very directly addressed. I know it’s slow — if you’re a primary care doctor out there — but I think there’s great hope that we’ll have much better reimbursement for primary care doctors going forward.

Q: Could you address your sense of how annual health care insurance premiums will increase under the act, as opposed to what might have happened had they not — had the act not been passed?

A: I think the impact on insurance rates is going to vary tremendously based on the type of group that folks are … particularly in small employer groups. … Younger groups will have higher rates, older groups will see lower rates, and so we’ll see a fair bit of change based on demographics and sex perhaps in small employer groups. In large employer groups, I don’t think that will be the case. I think we are seeing modification or mitigation of premium rates overall as a result of the delivery system changes that are going on, and so I’m optimistic that we will see lower premium increases than we would have seen had we not taken the steps that were taken in the Affordable Care Act.

Q: Could you talk a little bit more about the role of venture capitalists, capitalism in the industry and how that’s affecting care?

A: Sure. When you think about — we have a non-for-profit sector that is non-for-profit hospitals and other institutions. We have 700,000-odd doctors, many of whom practice in a very much for-profit context. We have for-profit hospitals out there and other for-profit entities providing post-acute care and operating in other segments of the industry. So there’s always been large amounts of private equity, venture capital — if you will — flowing into the health care industry. What’s changing, what I hope is changing — -and I think we’re seeing this now — is instead of that private investment flowing towards traditional medical delivery models like home care, fragmented home care, isolated [durable medical equipment] providers, we’re starting to see it flow into provider organizations that are actually interested in developing systems to deliver better health and better outcomes and lower costs. So that’s the exciting part. That venture flow is starting to seek out those kinds of organizations, and that’s very exciting. That’s what we need, because those organizations will need capital to get started.

Q: If half of health care cost is spent in life’s final six months, how do we re-evaluate end-of-life care?

A: I think we need a system that looks at managing every patient given their unique needs, wherever they are in the spectrum of having wonderful health to having a terminal illness. What we need to do is always ask providers to provide patient-centered care as better health, better care at a reduced cost. By the way, I should say, we measure each of those dimensions very directly with specific metrics looking for trending over time and improving in each of those metrics. I think the point to focus on is for every patient, working with them, to understand what their needs, what their desires are, regardless of where they are on that spectrum of health and life. And being sensitive to their needs, being explicit and clear and transparent about what they want, and then making sure that we have provider organizations that can deliver and meet those needs. So I would look at every patient in the context of a system that is based upon folks trying to deliver those outcomes.

Q: The questioner discusses dental disease as perhaps the most common. And why is dental disease treatment absent in the Affordable Care Act?

A: Well we have — there are some pieces of the Affordable Care Act that go at dental coverage for children. It clearly has not … I’m sure we could all hope for much more there than what we’ve seen. Within the Innovation Center we’ve identified a number of new initiatives that we are testing. Models of care delivery, specifically with dental, Delta Dental in South Dakota and out in the Midwest — looking at new care models to improve dental care and outcomes for children. So I would say, we’re looking at it — we’re looking at it within Medicaid. I keep saying “we.” I have trouble getting over that. But it was looked at, it’s continued being looked at, and I know the folks in Medicaid and the folks in the Innovation Center are very interested in looking at different ways of delivering dental care.

Q: Dental care to mental health. How does mental health fit into the Affordable Care Act? Can a person with a pre-existing mental health issue be eligible for insurance?

A: Yes, and there is no distinction to be made between folks coming in with a pre-existing behavioral health problem or a more typical medical problem. Neither would be allowed to be considered in developing rates. You know, I think at times, we’ll look back and say, “Really, we did that? We actually used to discriminate against people with pre-existing conditions or with behavioral health?”’ We’ll look back and say, “My god, how did we operate as a country doing that?” We’ll look back in a couple years and see that, and I think behavioral health — that will be the case with behavioral health. We’re also looking very closely at ways of integrating behavioral health into primary care and traditional medical care. Reintegrating it actually in some ways; we’ve kind of carved it out over the past 30 years. So there’s a number of programs that we’ve started up through the Innovation Center and within the [Substance Abuse and Mental Health Services Administration] that are looking at improving and integrating behavioral health into the overall spending. And of course there’s mental health equity requirements now so that benefits need to be equal with physical benefits.

Q: Will there be a continuing need for free health centers and clinics that currently serve the uninsured?

A: That’s a great question and, I think, obviously we’re not necessarily going to get everyone covered this time around, so there will be a continuing need of that sort, no doubt. But the thing that’s really exciting … is think of that 30, 35 million new paying customers. Think about the entrepreneurs who are going to say, “Wait a minute, maybe I want to go into business in Camden, N.J. Or Trenton, N.J. Or the toughest places in Chicago or New York.” Because now, there’s actually a marketplace to deliver care to folks where there wasn’t one before. That’s exciting. And the interesting challenge for federally qualified health centers and other safety net providers is, how are they going to fare in that environment? So they’re going to be driven just as much as other providers to actually rethink the way they deliver care and to focus on a much more patient-centered outcome — three-part aim outcome model of care. And I think they are concerned about that,  and I know that they’re thinking hard about what they need to do to keep their business. And isn’t that wonderful? They’re worried about it because are interested in providing that care as well.

Q: As we increasingly emphasize outcome-based rewards, who is going to take on high-risk patients?

A: We have some academic health center folks in the audience, I suspect. And it’s a great question. I hope that we will, and we are working hard to develop case mix adjustment capabilities that allow us to actually adjust payments for the mix of a particularly population — the illness-burdened population. Now, truth be told, in [Accountable Care Organizations] you typically will be assigned the population that you’ve taken care of. So that’s the population that is the sickest, that was the most expensive — if you’re an academic medical center — with that kind of a population. And so your target, for savings, will be much higher. So in large ways, in the ACO world and the medical home world, where we have shared savings programs, and in the model payment, you’re actually being judged against where you were before with that population. I would hope that we won’t see massive shedding of high-risk patients in that context, and we actually have provisions to monitor for that that were very specific in the regulations that were developed for the Accountable Care Organizations. So, more work to be done for sure, but the good news is we have a built-in casemix adjusting process in the Accountable Care Organizations system.

—Transcribed by Maggie Livingstone