This is the first in a blog series outlining Community Catalyst’s policy priorities for Health System Transformation. Each subsequent blog will take a deeper dive into one of the six areas we believe must be addressed to achieve better care, better value and better health.

Although much work remains to fully realize the coverage vision embodied in the Affordable Care Act (ACA), another aspect of the ACA—how we deliver and pay for health care—is receiving increasing attention. To date, the bulk of this attention has come from providers and public and private payers. But consumer advocates are coming to the table, increasingly recognizing that critical decisions about access, quality and affordability are being made.

With support from The Atlantic Philanthropies, Robert Wood Johnson Foundation, The John A. Hartford Foundation and others, and working closely with other national and state partners, Community Catalyst has committed itself to supporting an effective consumer voice in the debate over “Health System Transformation.” A necessary  (though not sufficient) step in this direction is to clarify what we hope to get out of Health System Transformation, what the risks are to consumers in a reorganized system, and consequently, what our agenda for change should look like.

What We Hope to Achieve

The Institute for Healthcare Improvement’s “triple aim”—better care/better health/lower cost—provides a good starting point to develop a framework for transforming our health system. But it can be made more specific by answering three questions:

Better care for whom? Primarily, for two intersecting groups:

  • people with multiple chronic conditions and disabilities who account for the bulk of our national health care spending and who are often poorly served by a system that is better designed to address discrete episodes of acute illness
  • low-income people, racial and ethnic minorities and other marginalized populations

Better health how? Better health will be achieved not only by improving clinical processes to get better health outcomes, but also by redirecting wasted resources in an inefficient medical care system to improve the social and economic conditions that generate a lot of acute and chronic health spending.

Finally, better value how? By addressing those features of the U.S. health care financing and delivery system that inflate our spending relative to other advanced industrial democracies but fail to improve clinical outcomes (see The Path to a People-Centered Health System for more discussion of these drivers of low-value care).

What Are the Risks?

  1. The push to achieve cost savings will come at the expense of better care and better health. We see this risk in the alarming trend toward higher patient cost-sharing, which can lower health spending but also puts the greatest economic burden on people with chronic conditions and low-income people.

  2. Plans and providers will seek to achieve results by avoiding or underserving high-need/high-cost patients. Reengineering care is hard. Relatively speaking, avoiding patients who might drag down quality scores or bust through budget caps is easy.

What Policy Agenda Can Help Us Realize Our Positive Goals, While Minimizing the Risks?

Community Catalyst has identified six areas we believe are critical to address in order to ensure that the promise of better care, better value and better health is realized and the pitfalls avoided.

1. Advance consumer engagement at three critical levels: individual, health system and policy development. At the individual level, the goals and experience of each patient should inform the caregiving process. At the delivery system level, there should be organized systems to integrate patients and patient advocates into the process of continuous quality improvement. Finally, at the policy development and monitoring level, consumer advocates must have a seat at the table along with payers and providers (and not just token representation).

2. Implement pro-consumer payment policies. This should encourage providers and health systems to address the needs of high-need/high-cost patients, reduce payments for overpriced goods or services and reward providers for improving outcomes.

3. Strengthen consumer protections. While patient engagement and appropriate payment policies are important consumer protections, they are likely not sufficient in a system that puts providers at risk for the cost of care. In order to guard against under-service, a robust set of consumer protections, including grievance and appeal rights, and consumer-oriented quality measurement and reporting is needed.

4. Place care coordination at the heart of delivery system reform. In order to improve care and outcomes, especially for people with multiple chronic conditions, consumer advocates will have to ensure that care delivery models, such as patient-centered medical homes and accountable care organizations, incorporate team-based care approaches and integrate physical and behavioral health services.

5. Redirect resources to address social determinants of health. Many factors that lead to high spending and poor outcomes lie outside the delivery of medical care per se. Indeed, when spending on health and social services is combined, the U.S. is less of an outlier compared to other countries. It focuses more of its spending on medical care and less on primary prevention, so people don’t get sick in the first place. Part of the goal of system change should be to correct this imbalance.

6. Promote health equity. Many important strategies to promote health equity are addressed under other priorities, but the topic deserves special attention because health disparities are likely to persist or even widen as system reform unfolds. Racial and ethnic health disparities impose significant costs both from avoidable health spending and from lost productivity. A multi-faceted strategy must include data collection, adequate funding for currently underserved communities and populations, diversifying the health care workforce and promoting culturally competent care.

Obviously, much more detail is needed to fill in this ambitious agenda and make it actionable. In the weeks ahead, we will use this blog series to drill down on each one of these topics.

We also recognize that all of this change will not happen overnight. Placing these priorities at the heart of efforts to transform the way we pay for and deliver health care and how we promote health more broadly will require sustained advocacy over many years. We welcome feedback on this agenda from our state and national colleagues and from other stakeholders, and look forward to making the promise of better care, better value and better health a reality.