Daly: Is there any of this that you're mad about?
Fifer: I really try not to get angry about anything. I get disappointed and frustrated, like with the issues I've mentioned. I get disappointed when there is a lack of courageous leadership. So, I'm saying, let's try stuff, and we can adjust as we go forward. On putting the transparency tools out there, the thing that will make them the best is getting the feedback from patients and finding out what they like the best and what they don't like. It’s about giving it your best shot. I don't think that best effort is occurring, and it is a leadership issue.
Daly: Sometimes it appears that problems in healthcare either stem from or are exacerbated by disconnects in the outlook of leaders. Where do you see the biggest disconnects, and what is their significance?
Fifer: One, we have a fragmented system. The provider side is fragmented. When you're seeking care, oftentimes you must seek that care from multiple different entities. The payer side is very fragmented. Simply speaking, roughly half our typical organization's revenues would come from government sources, like Medicare and Medicaid, and the other half from private sources, largely employer-based insurance.
The second reason is that the industry is under pressure and therefore under scrutiny on the economic side.
The third factor is the size of the industry, just the fact that it is one-fifth of the economy.
When you combine all those things, it adds up to a pretty explosive environment and leads to all kinds of disconnects. There are four major constituencies that contribute to healthcare: the payer environment, or insurers; providers, in which I would group hospitals and other clinicians; the business community; and patients/consumers.
The disconnects among all those are almost too many to list. An example might be that most times patients expect to be able to use all providers in any given community or even outside their community. Another one would be that patients don't expect to be surprised with a bill. That's a very reasonable expectation, whereas maybe you could argue the expectation of having access to all providers is unreasonable. This industry is full of disconnects, and it comes back to a lack of communication in so many respects.
Recently, it dawned on me that with all this fragmentation, we haven't yet defined the transaction in question. When we buy other consumer goods, we know what the transaction is.
In healthcare we have not identified it. Is it acquisition of health insurance? Is it the purchase of hospital services, physician services or those from other clinicians? Is it the funding of our federal or state governments?
When we don't know where to focus, don't know the one transaction, and the costs are increasing, then everyone starts to look like a villain, which adds to the disconnect.
Daly: That potent combination of pressures could produce some unexpected results. Where do you see healthcare going in 2020 and the coming decade?
Fifer: I feel better about making a longer-term prediction than I do about 2020. In 2020, there's so much uncertainty. I expect Democrats to hold the House of Representatives and perhaps win the White House. Even if the Democrats win the Senate, it would not be enough to avoid a filibuster. So, in that scenario there is not an environment where we would have big sweeping changes in healthcare. You could make that argument no matter who wins the White House.
That means with no big sweeping change, we'll continue to make gradual incremental changes in the industry. Similarly, the movement to value-based payment will remain at a snail's pace. Congress will pass some bills, such as surprise-bill legislation and the drug pricing measure. Maybe some of that will be handled through regulation versus legislation.
I've been hesitant to address the long term publicly, given that HFMA is politically agnostic, but I think we're going to end up in the long term with Medicare Advantage for All. There are elements that would make the left happy: universal coverage. There are elements that would keep the right happy: market forces, it would allow for choice — in each market you could choose between multiple health plans. In a Medicare Advantage for All environment, we would focus on the purchase of health insurance that fits what consumers need.
Lots of folks will get mad at me for saying this, but why not approach this like other complex things that we buy, like cars and phones? If we focus on that transaction, hospitals would be a supplier to that transaction, just like there are all kinds of suppliers to automakers. Part of the benefit is that it would focus us on that insurance-purchasing transaction in a way that people in this country could understand. Once that focus starts to get simplified a little bit, then perhaps other things would start to line up. It would be funded by a mechanism that would provide for universal coverage. This approach satisfies both ends of the political spectrum, by which I mean it irritates both ends.
The cost pressures are going to continue to mount in such a way that we are going to need a big-time solution on the table, rather than this incremental change we've been discussing.