Mark McClellan on the Affordable Care Act: 'It's an important step.'
Mark McClellan is the director of the Engelberg Center for Health Care Reform at the Brookings Institution. Before that, he served on George W. Bush's Council of Economic Advisers. Bush subsequently appointed him head of the Food and Drug Administration, and then director of the Centers for Medicare and Medicaid Services. We spoke this morning about the Affordable Care Act and the next steps.
Let's start with the basic question: Is this a step forward?
It's an important step. We have to do something about the problem of access to affordable health insurance. The bill unquestionably does that. The provisions related to changing provider payments are significant in terms of their potential for reducing spending growth, though I'd have liked to see more of those steps.
So which provisions do you find encouraging?
The provider payment reforms. The president likes to say that all the good ideas experts have are in the bill, and that's largely true when it comes to payment reforms. But since we don't know exactly which of those reforms work, we'll have to find out quickly. And that will require doing a fundamentally better job of running the pilot and demonstration programs in Medicare. Right now, we evaluate the reforms over 8 to 10 years. We need to lower that. Particularly since we've got the payment advisory commission that has some ability to modify payment rules, but it has some limitations (hospitals are excluded for 10 years). Since we don't have as much evidence as we need on what works to lower costs, we need to make sure they get that evidence as soon as possible.
People talk about the payment reforms in the bill a lot. Could you be specific about which ones you think are promising?
There are a lot of different ideas in there. Many of the ideas relate to pay for performance, paying more when doctors do particular things. I think those are important, but they're unlikely to transform health care by themselves. And they do run the risk of getting doctors and hospitals to teach to the test and be too specifically focused on the particular issues identified in the legislation.
More important, I think, are the reforms that pay doctors and hospitals more when they get better outcomes for people at a lower overall cost. That would be steps to encourage using nurse practitioners to help patients with chronic diseases manage their illness, changing where care is delivered from an inpatient to outpatient setting, paying for reducing the complication rate. The most important reforms on the payment side don't tell doctors and hospitals what they need to do or but support them when they figure out how to do things better.
And what would you have added to the bill?
I was part of a bipartisan group of economists and other health-care experts that did a report on bending the curve. On that list, but not included in full in the bill, was reform of the medical liability system. We also included a big emphasis on consumer side reforms. If people could take steps to stay healthier and reduce their complications, we could provide support for them as well. Under our current insurance arrangement, if you have a serious chronic disease where you need to go to the hospital for major surgery, you're probably going to be paying your out-of-pocket maximum no matter what. It shouldn't be like that. If people use providers who have demonstrated that they can get better outcomes with fewer complications, we should support them in that.
One interesting thing I find is that when I talk to health-care experts they talk about things that happen in hospitals and doctor's offices, as we're doing here. But the political discussions is mainly about insurance reforms. Do they fit together?
It all fits together. Unless you have compelling information on quality of care and cost of care, it's hard for them to make choices. And it's frustrating for everyone in the system right now. When I was at CMS, providers came to me and said we can show we're delivering better care at lower results, but we don't get paid for this. In fact, we lose money because we're doing less of the traditional billing: We've got fewer lab tests and doctor visits. I think this will help us get to where we can support those steps, but it's not a sure thing.
Let's say it's eight years from today, and you're brought back not just as director of CMS, but as health czar. What do you do to the system? What are the next steps?
There may be less expensive ways to provide insurance, and we'll know more about that in five years. I also want to make sure people can choose innovative kinds of plans and innovative kinds of care based on what we learn over the next five years. If we're making this investment now, then by five years from now we'll hopefully see insurance plans that look very different, that don't automatically make you pay $15,000 when you have a serious illness but reward you for making good decisions. I want to make sure our insurance exchange really promotes that kind of coverage. And by that point, we'll probably have to take some further steps in controlling costs.
March 26, 2010; 9:02 AM ET
Categories: Health Reform , Interviews
Save & Share: Previous: Beneath the Obama agenda, the Obama agenda
Next: What do conservatives believe about health care?
Posted by: tjmlrc | March 26, 2010 9:59 AM | Report abuse
Posted by: visionbrkr | March 26, 2010 10:13 AM | Report abuse
Posted by: mglbrown1 | March 26, 2010 10:21 AM | Report abuse
Posted by: andym108 | March 26, 2010 10:37 AM | Report abuse
Posted by: theobserver4 | March 26, 2010 10:49 AM | Report abuse
Posted by: tjmlrc | March 26, 2010 10:51 AM | Report abuse
Posted by: Fletch_F_Fletch | March 26, 2010 10:52 AM | Report abuse
Posted by: mglbrown1 | March 26, 2010 11:01 AM | Report abuse
Posted by: bharshaw | March 26, 2010 11:10 AM | Report abuse
Posted by: Meridian1 | March 26, 2010 11:15 AM | Report abuse
Posted by: SCVoter | March 26, 2010 11:16 AM | Report abuse
Posted by: Lomillialor | March 26, 2010 11:27 AM | Report abuse
Posted by: visionbrkr | March 26, 2010 11:27 AM | Report abuse
Posted by: visionbrkr | March 26, 2010 11:27 AM | Report abuse
Posted by: maiapapaya | March 26, 2010 11:36 AM | Report abuse
Posted by: sally62 | March 26, 2010 11:36 AM | Report abuse
Posted by: wimprange | March 26, 2010 11:49 AM | Report abuse
Posted by: wimprange | March 26, 2010 11:52 AM | Report abuse
Posted by: jgp38 | March 26, 2010 11:59 AM | Report abuse
Posted by: maiapapaya | March 26, 2010 12:07 PM | Report abuse
Posted by: tpokalsky | March 26, 2010 12:21 PM | Report abuse
Posted by: AntonioSosa | March 26, 2010 11:04 PM | Report abuse
Posted by: rmgregory | March 27, 2010 2:54 PM | Report abuse
Posted by: tpokalsky | March 27, 2010 3:58 PM | Report abuse
The comments to this entry are closed.