How about these HHS priorities, Secretary Price?
In August, I attended the Medicaid Enterprise Systems Conference where the Department of Health and Human Services (HHS) Chief Technology Officer (CTO), Bruce Greenstein, used the following slide:
I was surprised by this list, so I did a little digging to see how it came about. In March, in front of a House subcommittee discussing the President’s budget, Secretary Price highlighted three slightly different goals: 1) mental health and substance abuse; 2) emergency preparedness; and 3) childhood obesity. However, in June, in front of the Senate Finance Committee, Secretary Price affirmed the first three goals mentioned above in CTO Greenstein’s slide. Since I cannot find a clear statement of Secretary Price’s goals for HHS, I must be within the window to influence. I am excited to help him think of bigger goals and priorities for HHS under Secretary Price’s tenure in order to help drive the Department towards health system improvement.
To give you an idea of scope: There are over 80,000 employees in approximately 30 agencies with a fiscal year 2018 budget of $1.131 trillion in outlays (52% Medicare, 39% Medicaid & CHIP, 7% other discretionary programs, 1.5% other mandatory programs, 1% cash assistance/TANF). Some of the agencies in HHS include the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control (CDC), the Food and Drug Administration (FDA), the National Institutes for Health (NIH), Indian Health Services (IHS), and the Substance Abuse and Mental Health Services Administration (SAMHSA). The Health Resources Services Administration (HRSA) is responsible for the nation’s safety net of free and sliding-scale urban and rural clinics and hospitals, as well as the providers who staff them, among other things. Also the Administration on Children and Families (ACF) handles a number of critical matters like foster care youth, child support collections for all people, refugee resettlement, early childhood education, and non-Medicaid family planning programs. The Office of the National Coordinator for Health IT handles standards, interoperability, and planning for health IT programs. And that’s just all off the top of my head.
HHS leads the largest payers of healthcare in the world, it has some of the brightest scientists, policymakers, actuaries, and technocrats; it some of the most compassionate caregivers, clinicians, and program managers; and it has some of the most talented leaders… this talent can be harnessed into more ambitious goals for the Department.
If I were Secretary Price, I would have all the data systems and amazing HHS staff at my disposal and I don’t. I’ve got Google. And I’m spending a couple hours on this. So here is a first cut at what his goal for the Department could be, keeping in mind that this is no longer an Obama HHS. I’m trying to keep the current Administration’s priorities and promises in mind, as well as the fact that I know they want to be good stewards of the public programs.
My proposed goals for HHS under Secretary Price’s leadership are in four categories, as follows:
- Access to Care. The only way to achieve improved public health in the U.S. is when everyone has access to high quality, affordable health care.
- This includes ensuring that every veteran is covered. Access to health care services can prevent and stabilize veterans from some of the issues that cause homelessness and suicide.
- This is a key issue in fighting the opioid epidemic to ensure everyone can receive the behavioral health (mental health, substance abuse), primary care, and non-pharmacological pain management treatment they need.
- Continue integrating primary and behavioral health services.
- Reducing disparities in care wherever they exist: urban/rural, race, gender, age, etc.
2. Prudent Government Spending of Healthcare Dollars.
- Continue to pursue research-designed, value-based purchasing models with input from stakeholders in provider, IT vendor, consumer, and commercial payer communities.
- Look for opportunities to encourage consumer “skin in the game” where data will show it is effective and not wasteful of government resources. Encourage innovation in this space through sharing data. This could include consumer crowdsource of fraud/abuse monitoring, patient-reported data for analytics, etc.
3. Public Health and Clinical Care
- Promoting improvement in any of the leading causes of death in the U.S.: Heart disease, stroke, and diabetes (853,700), cancer (595,930), chronic lower respiratory diseases (155,041), and suicide (44,193).
- Addressing the opioid crisis. Use and promote reimbursement methods and utilization management tools with proven success to drive down over-prescribing. Continue to deploy grant funds for clinical services and interventions. Encourage multi-agency work to address families in turmoil, support the foster care system, etc. Strategic planning around state workforce development and resource planning.
- Emergency preparedness (this was on one of his lists above, when he spoke to a House Subcommittee in March and is a good one). Promoting national, state, local, and individual/family safety and preparedness response for a disaster or national emergency.
- Measure, evaluate, and reimburse providers for improved care to patients who lack access to care across a number of social determinants of health. (Note: This may result in higher reimbursements to providers who improve a patient’s health when their baseline across a number of domains is low — e.g., housing, education, etc.)
- Zika/pregnancy. This continued public health threat will continue to test our ability to contain a viruses and reduce their infiltration through education, testing, and management.
4. Technology and Science
- Antibiotic resistance. This is a global threat and it is serious.
- Bring down the price of prescription drugs through transparency and innovation. Reducing the price of prescription drugs is one of the linchpins of reducing overall healthcare costs and a stated goal of the President.
- Improve automated provider data submission rather than removing the programs that rely on this. Make the systems more interoperable. When a vendor is dominating the market, refusing to affordably provide these services, then the government needs to leverage its tools to make the market more competitive.
This last one refers to Secretary’s Price’s fourth goal on the slide at the top. Reducing clinician burden is a well-known bugaboo of his, predating his time at HHS to when he was a Congressman from Georgia. Secretary Price was an orthopedic surgeon and owned a very large practice, so he is familiar with CMS reporting requirements. His well-known position on this issue is starting to impact bipartisan policies such value-based purchasing and electronic health record initiatives that require provider data clinical data reporting. This week CMS notified providers in a blog post that they will continue to look for ways to reduce provider burden. This alone is not a problem. The issue is that the submission of this data is critical to measuring the value of the health care people receive. This should probably merit a longer post on why this matters, so I’ll come back to this another time.
I would not put childhood obesity on this list. Especially when things like the Child Nutrition Programs (i.e., the School Lunch Program) are under the purview of the USDA, not HHS. Local school departments govern curriculum for Physical Education, leaving few formal federal policy levers for HHS. Most other policy levers are in the domain of state and local authorities. HHS can and should support these efforts, but this probably is not a top line goal.
As for addressing Serious Mental Illness (SMI), the Secretary’s testimony from June above addresses this goal, but does not make it clear why he picked this. He differentiates between SMI and other mental illness, but it is not clear why. In any case, I do not see a lot of value in drawing these lines around mental health services and it is best to address broader mental health in conjunction with other comorbidities, such as substance use in order to more holistically treat an individual’s condition.
While I am not philosophically aligned on all of Secretary Price’s objectives, I know we can agree that a stable, efficient, high-quality health care system is achievable under these four goals. I look forward to seeing an HHS that promotes innovation, leads through clear-eyed policy, and continues to staff their agencies with the best and brightest.
