Health Care 2021 A New Golden Age?

What will New York's health care system look like in 2021? What should it look like? These were the challenges taken up in a conference sponsored by UHF and the New York State Health Foundation in early February. They are also at the core of our daily work.

With the potential at hand for fully integrated care and technology that provides needed information about all patients at all times, this could be “a golden age for health care delivery,” asserted keynote speaker George Halvorson, who for more than a decade was CEO of Kaiser Permanente, perhaps the nation's best example of an integrated health care delivery and financing system. At the core of such success, he said, is a culture designed to make doing the right thing the default option in all circumstances.

That's a highly aspirational vision, one based on a number of essential elements.

POSITIVE TRENDS MUST CONTINUE
Most critical is the continued march toward universal coverage. Recent reports indicate that more than 2.7 million people have gained coverage through New York's health insurance exchange, reflecting the State's strong commitment to the Medicaid program, a new Essential Health Benefits program covering approximately 300,000 people this year, and subsidized coverage available through the Affordable Care Act. New York now has a single-digit uninsured rate, with one report indicating a number as low as 5 percent—extraordinary, given the 15 to 17 percent of New Yorkers without insurance approximately a decade ago.

Second, New York must control overall health care spending and address out-of-pocket costs to individuals. While aggregate health care expenditures challenge both the national and state economies, out-of-pocket spending is a major stressor for the many New Yorkers with limited income and assets. A key to cost control, and an essential five-year goal, is value-based payment, replacing the expensive and fragmented fee-for-service system that has been the rule.

Third, all New Yorkers should have access to the benefits of the patient-centered medical home and advanced primary care models, with full linkages to specialized services likely provided by the integrated provider systems now emerging.

Fourth, there must be continued strides in adopting information technology that provides consumers with meaningful data on the quality of services and allows for decentralized care. Via telemedicine the potential exists, our conference keynoter indicated, for up to 40 percent of care currently provided in clinics and doctors' offices to be shifted to the more convenient, less expensive setting of the home.

THREATS TO THE VISION
What are the major threats to all this being accomplished? First is a continuing call to repeal and replace the mechanisms that have so expanded coverage in recent years. While it's easily argued that there may be unneeded complexity in the application of subsidies within the system, New York's record-high levels of insurance coverage are evidence that we must not retreat from fully implementing the ACA and Medicaid reforms.

Second is the risk that the financially fragile independent and public hospitals that are primary providers of health services in low-income communities are left to flounder.

Third, while consumers will benefit enormously from information on health care quality and available options, they cannot be expected to make critical health and economic decisions on their own. Care must be taken to differentiate the varying circumstances of patients and build quality reporting on measures important to patients themselves.

Fourth is the possibility that New York does not see to successful conclusion the extraordinary work it has begun under the Delivery System Reform Incentive Payment program, State Innovation Model, and Statewide Health Information Network of New York. These three initiatives—on service delivery, payment reform, and health information technology, respectively—have the potential to transform New York's health care by 2021, but there was skepticism expressed at the conference about their prospects for completion.

The potential for a fully integrated, financially stable health care system exists, given continued commitment to the promising initiatives of the past few years. We may not recapture the fabled golden age of antiquity, but we can ensure an era of high-quality care at affordable cost for the vast majority of New Yorkers.