Page 12 - Volume 70 Number 1
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Mark Fendrick
Goes to Washington
by Richard E. Burney
For over 10 years, University of Michigan Internal Medicine Professor Mark Fendrick has grappled with the problem of health care cost and championed the idea that we should be seeking and paying for good health care – i.e., care that improves health – and that we should not be seeking and paying for health care that is harmful, which in his view we do every day. This seems like a logical goal to pursue, but how do you go about doing that in our crazy, irrational system of health care coverage and delivery? How do you create incentives that encourage patients to seek
– and enable physicians to provide – valuable health care services, such as preventive care, childhood vaccinations, and eye doctor visits for diabetics while discouraging patients from seeking – and physicians from providing – services that pay well but don’t actually provide value? How do you enable patients to easily obtain needed services – for example, by lowering financial barriers – and discourage them from seeking easily obtained but possibly harmful services and tests? His answer is called Value-Based Insurance Design (V-BID), which he and colleague, Michael Chernew, developed a decade ago, and which, with persistent and persuasive effort, has found its way into major health care legislation, such as the Affordable Care Act (ACA), and regulations found in the Medicare Advantage plans.
I was intrigued a few months ago when I saw that Dr. Fendrick had recently testified before a congressional committee about V-BID, and since testifying before a congressional committee is something most of us will never have the opportunity to do, I wanted to learn more. Getting your ideas before a House or Senate committee is not so easy to do. Nor is coming up with something that can get bipartisan support. (https://waysandmeans. Testimony-Fendrick.pdf)
To learn more, I talked to Fendrick in his office at the Institute for Health Policy and Innovation Building in the UM North Campus Research Center.
Selling an idea in Washington is not easy. To quote Fendrick, you need to have a “strategy that include(s) conceptual framework development, program implementation, rigorous evaluation, media outreach and an advocacy plan.” It also takes a team.
It helps to start with a premise that both sides can understand and happily agree on. Fendrick’s premise is this: There is enough money in the health care system; we just do not spend it wisely.
Next, you frame your arguments in ways that have something for both sides to love: for liberals, all essential health care services will continue to be provided; for conservatives, patients will take more personal responsibility for their choices.
Then you look to an unbiased, external evidence base to support your choices of high and low-value care. There is, for example, general agreement from the U. S. Preventive Health Services Task Force, and from other such politically disinterested organizations, on which health care services are the most beneficial – those for which barriers should be reduced or eliminated – and for services that are potentially harmful, for which barriers should be erected.
The single most effective type of barrier is financial
– out of pocket cost to the patient on the one hand and, on the other hand, the revenue received for services. Lowering costs for patients encourages utilization of services; increasing reimbursement encourages physicians to provide those services. At present, neither incentive obtains. Co-pays by and large are the same for all services and reimbursement for essential services may well be lower than for less valuable ones.
The same argument can be made for cost of pharmaceuticals: why should the co-pay requirement be the same for prescriptions of little value – think antibiotics for viral infections – as for drugs that are known to be of proven clinical benefit.
You Need More than a Good Idea
To influence policy at a national level you have to do a lot more than have a good idea. No matter how good your ideas are, the usual academic route of putting them in peer-reviewed publications, will not get them before the decision makers in Washington and universities of late have shied away from going there. The V-BID team that went to Washington, led by Fendrick and Jenifer Martin, J.D., who had experience working in the federal government, assembled itself through a combination of three things: 1) suggested personal contacts who might
12 Washtenaw County Medical Society BULLETIN JANUARY / FEBRUARY / MARCH 2018

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