An Open Letter to Senator McCaskill

Dear Sen. McCaskill,

Taking on issues like access to healthcare, transparency in the cost of care, affordability and the ability for healthcare consumers to make informed decisions is way overdue. So when a colleague passed along some information about your recent activism on the subject, I was excited and encouraged by your interest!

As the CEO of a healthcare data and analytics consulting firm, these are issues that occupy my life. I work consistently with organizations on both payor and provider sides of the healthcare industry and I can tell you from personal experience, the drive for change is alive and well. But, as you know, solutions for issues of this magnitude require a coalition of support. To achieve real change, it’s going to take payors, providers and patients working together with allies in business—like me—and government, like you. To that end, I wanted to offer up my thoughts for policy that could help address some of the underlying issues in healthcare that are contributing to the larger problems of rising costs and timely access to quality care.

One of the challenges in healthcare is that it’s complex and has multiple key stakeholders who only see the problem through their own lens. This makes it near-impossible to reach a common understanding about the root cause of the issues. Without it though, we can’t expect to agree on a solution that aligns with the best interests of everyone involved. You recently brought together patient advocates, ER doctors and community health workers for a round-table. That’s a fantastic start! But, I’d advocate for including additional stakeholders like health insurers and hospital administrators in this discussion. They are setting policies, negotiating physician reimbursement rates, and looking at the system from a population level. Theirs is a unique perspective that could result in more effective policy—and we won’t be able to create a workable solution without them.

It also cannot be understated how flawed Anthem’s ER policy truly is. Even with the recent changes, it serves as a perfect example of the futility in trying to solve the big challenges of healthcare in isolation. In their effort to fight a systemic battle against inappropriate use of ER services, they’ve made a policy based on incomplete information. It’s incomplete because it is only using financially related data from a medical claim—the  diagnosis codes as described in the LA Times article you’re quoted in. Diagnosis codes are an ontology used in the determination of the financial disposition of a claim. Will the claim be paid? If not in full, how much? These diagnosis codes occur after the episode of care and are missing key pieces of information found in medical notes, physician observations, imaging or lab results and human interaction.

This extreme position also ignores so many additional factors that come into play when someone shows up at the ER; such as the behavioral health of the patient and social determinants of health like transportation, education and housing. So again, we’re talking about an underlying issue in the health system that is contributing to a larger problem. Making a difference will require consideration of people’s health as a whole, transforming fee-for-service to a value-based payment model, and the pursuit of policies that break down the walls to encourage and incent the sharing of information so these other types of data can be more readily available to physicians and policy makers alike. 

We have learned from working with our clients that proactive and purposeful policies related to ER utilization are most effective; educate the patient on options and price for care; look at a person’s health as a whole using social determinants of health; better care management to inform and monitor treatment after discharge and engaging patients to avoid care in expensive emergency settings.

It is encouraging to see these issues are being understood and taken up by policy makers to make a difference for all Missourians. We look forward to having an opportunity to work together with you and other leaders in the healthcare industry on developing smart, common-sense solutions.

Best Regards,

Amit Bhagat CEO, Amitech