HIStalk Interviews Andy Slavitt, Former Acting Administrator, CMS (Part Two)

Andy Slavitt, MBA was acting administrator for the Centers for Medicare and Medicaid Services from March 2015 until January 2017.

This is Part Two of the lengthy interview. Topics in Part One included perceptions of the healthcare system, high healthcare prices, doing a better job of explaining the Affordable Care Act, risk pools, and the individual mandate.

Experts thought high-deductible plans, which is a lot of them these days, would encourage people to become wiser healthcare consumers. Studies suggest that didn’t happen, that instead people who can’t afford to pay the deductible are avoiding getting care.

You’re right and you’re wrong. You’re right in the fact that we don’t have a functioning market that people make rational decisions because they’re paying out of pocket. You’re wrong. though. in how you’re characterizing what insurance looks like and feels like to people.

There are meaningful differences in the number of people today that say they can afford to take their medications — and do take their medications — than before the ACA. There’s meaningful differences in the number of people who report having a regular relationship with a primary care physician than before the ACA. There’s meaningful numbers of people who say they are satisfied and can sleep better at night because of coverage.

Two-thirds of policies have primary care outside of the deductible. About the same number — actually it’s more than that, it’s about 80 percent of policies, last I saw — you can get three primary care visits outside your deductible. About two-thirds have prescription drug coverage outside of the deductible. Lesser numbers,  you can see specialists and have name-brand drugs outside of the deductible. Preventive care is free. There’s a whole package of things.

By the way, cost-sharing reductions have meant that up at least until 2016 — I haven’t seen the data for 2017 — the average out-of -pocket costs, i.e. deductible and co-insurance, have declined every year slightly. They’re about flat, but they have actually declined from 2015 to 2016.

There’s this mass media perception driven by, I think, a lot of propaganda which isolates several of the stories. Particularly, again, of the middle-class people that people are paying attention to, but it’s about 2 percent of the population as a whole that’s showing these higher deductibles.

I’m not a believer that higher deductibles make people better shoppers. I do think that the package of things in the ACA — given what you said earlier, which is that we have to work on unit cost and healthcare is still too expensive — is a darned good package for people and really valuable. Because when things happen, they will have the out-of-pocket max and then they have no limit in terms of what’s covered.

It’s a really great deal. Can it be made better? Of course. Of course it can be made better if people really put the spirit to it.

Did we as taxpayers get our money’s worth in funding $35 billion in EHR incentives?

Not yet. Not yet we haven’t.

Here’s what we’ve accomplished — and I’m sure you could agree or disagree and have as much knowledge base if not more than I do on this topic — but there’s now what I call a chicken in every pot. You walk into a doctor’s office, you walk into a hospital, they have technology there. It’s not as connected as it should be, it’s not giving people the information they need. It’s not satisfying the clinicians in general. it’s not increasing their productivity. It’s probably not improving care.

But remember, before the ARRA, we didn’t even have the means to have the technology to hook up. We’re sort of like using computers pre-Internet, wondering why our factories aren’t getting more productive. We’ve got computers and it’s just basically fancy ways of writing down what we used to do in pen and paper. 

It has come some of the way. We clearly, though, have productivity breakthroughs, Moore’s Law breakthroughs, and other breakthroughs ahead of us. I don’t think anybody should lose promise in the power of what technology can do and that that investment will eventually pay off.

But if not, we need to be very honest about the barriers. We need to be very honest about what it’s not doing.

I get a little bit sickened every time I go to HIMSS, in some part, because we’ve got this massive industry that puts on a great party and has massive shows, and yet they have a customer base that is basically unsatisfied with the product. That seems like it’s where we should put all our energy.

Are incentives aligned to use technology to improve care?

You’d like to think that’s where it goes next. That’s exactly where it has to go next. If you’re an internal medicine physician seeing patients every day, people should be building things for you to help you do a better job with your patients, and that they feel and that you feel.

I just got back from a trip in Silicon Valley. I visited with some of the country’s and world’s best technology companies, and the way they do things … I mean, complex problems have been solved before. Let me give you an example.

Before TurboTax, you literally had to sit down with the tax manual and a bunch of forms and do a bunch of back and forth, back and forth, and back and forth. It took people weeks to do what you can do in like 20 minutes now. You don’t even have to accumulate your forms — for most people, they’re automatically lined up and populated. If you stacked up the IRS code, it would be over your head by double in terms of the volume of paper. They took all that, they codified it, and they put it some simple yes and no questions and preloaded all the information.

Doing your taxes now is a breeze. In fact, you’re not even focused on getting them submitted. Now you’re focused on, "How do I optimize to get my best refund?" and so on and so forth. That’s a pretty good analogy for the complexity that’s in healthcare systems.

They could have had you fill out the IRS 1040 form on the computer, typing into something that looked like the form. They didn’t. That’s what you have with EMRs. You’re basically going through and filling out a billing record instead of something that is helpful and intuitive to a doctor and a patient.

I don’t think it’s hard, It doesn’t happen for a variety of reasons, of which I’m happy to talk about, but I think that’s exactly what needs to happen.

What does your post-government career look like?

Everybody tells you when you leave the government, you shouldn’t make any decisions for 90 days. You should just take in all the incoming and hear what people have to say. I’ve already kind of violated that, I think, because we’re just in a special moment. I’m going to keep a presence in DC. It won’t be a full-time thing. I’ll announce in the next few weeks where that’ll be.

Essentially, to the extent that I can be helpful as sort of an honest broker, what we really need to do is stop healthcare from being either a Democratic issue or a Republican issue. It wasn’t great for us as Democrats. Republicans are finding it’s not great for them, either. But more importantly, the country, patients, physicians, innovators, and hospitals just will not be able to afford the back and forth and the high-risk, high-stakes nature of this. People resent having their healthcare politicized.

I’m going to do something. It will be in a more pragmatic fashion. I’ve been really doing that on the road, talking to CEOs, talking to governors, talking to people on the Hill, anybody who needs help and is working on an honest path towards a solution.

Other than that, I’m free, so I’m spending more time with my family and I’m letting the phone ring. People want to talk to me about something and it seems interesting, I’ll talk to them and see where I can be helpful. A lot of people are trying to figure out what to do next, so it’s a nice thing to be able to do to be able to help your friends when they need help. I’m in no rush to tie myself up for the next long-term thing as long as I can be helpful doing what I’m doing. I’m speaking and I’m writing and I’m convening sessions and so forth.