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FAIR Health Board Access Interview with Sherry Glied, PhD

FAIR Health Board of Directors member Dr. Sherry Glied is a leading health policy expert, economist and scholar who is currently the Dean of New York University’s Robert F. Wagner Graduate School of Public Service. She was confirmed by the US Senate in June 2010 as Assistant Secretary for Planning and Evaluation at the Department of Health & Human Services (HHS) and served in that capacity from July 2010 through August 2012. Dr. Glied previously served as Senior Economist for healthcare and labor market policy on the President’s Council of Economic Advisers under Presidents Bush and Clinton, from 1992 to 1993, and participated in President Clinton’s Health Care Task Force. The recipient of numerous honors, she is a member of the National Academy of Medicine and of the National Academy of Social Insurance. Four years ago, Dr. Glied spoke with FAIR Health as part of the Board Access interview series regarding the impact of the Affordable Care Act (ACA) and cost transparency on the healthcare landscape. Dr. Glied recently spoke again with FAIR Health in a follow-up conversation about both the challenges and opportunities presented by the healthcare system today.

FAIR Health: Having served as the Assistant Secretary for Planning and Evaluation during the Obama administration, you advised former HHS Secretary Kathleen Sebelius on health policy development and the implementation of the ACA. What has most surprised you about the ACA’s rollout and impact thus far on the healthcare market? What are some key opportunities for improving healthcare quality and access while controlling the growth of costs?

Sherry Glied: Many of the forecasts about the ACA rollout envisioned that people would switch out of employer plans and move into the plans sold on the health insurance marketplaces, but that hasn’t happened. People seem to like having employer-sponsored health insurance. We also hadn’t counted on how often people change plans, seemingly at the drop of a hat. We had thought, probably mistakenly, that people would be fairly loyal to their plans, but it seems that individuals are very prone to switching plans to find a better price. The amount of plan-switching has caused significant instability in the markets.   In the same period of time, though not really related to the ACA, we have learned that there is a great deal of price variation in the private healthcare market—both the amounts paid by private insurers to healthcare providers as well as the amounts that providers charge. We didn’t have the data before, but now that we do, we can see that there is much more variability in prices than we had anticipated. This variability in both market charges and in the amounts that insurers pay providers creates opportunities when thinking about how to make the market more competitive and structure prices so that they better reflect value. And, with respect to access, the most important thing is to maintain the gains that we have realized: ensuring that marketplace enrollment continues, that states participate in the Medicaid program and that we encourage and make it easy for people to enroll in Medicaid. If we don’t stabilize the markets and they deteriorate, people will not enroll in plans, which will be bad for those individuals and for other stakeholders, as well.

FH: When we spoke four years ago, you noted that improving the quality of the nation’s mental health care would involve ensuring that people have access not just to care but to effective care. How would you characterize the progress that has been made on this issue over the past four years? And, in a topic closely related to mental health, what policy changes are necessary to managing the nation’s opioid epidemic?

SG: We have definitely seen improvements in access to care, and in access to effective care, at that. Perhaps the most challenging issue in the mental health sphere right now is that our healthcare delivery system is treating the opioid crisis and mental health quite separately, as if substance abuse is off on one side and mental health is on another. These are, if not two faces of the same coin, highly interconnected problems. Under healthcare reform, people are covered for both mental health and substance abuse services. Parity is required for those services in relation to each other and to other healthcare services. Medicaid expansion has enabled many people to access substance abuse services. But, the integration of mental health and substance abuse services has not happened. That integration will be key to addressing the opioid epidemic.

FH: The national healthcare debate has focused largely on controlling costs and increasing coverage. What other issues should be given greater attention in the public forum?

SG: Increasing coverage and controlling cost, in that order, seem to be the most important elements to focus on. But, of course, we also need to focus on quality on three levels. The first is eliminating very low-quality services—by either improving the quality of low-quality providers or removing those providers from the market. Second is improving the average quality of service provision, particularly when thinking about technology and new kinds of providers that can actually help improve quality in the middle of the market. Making care more accessible is a corollary to quality. I am intrigued by the growth of minute clinics, which I think address an aspect of quality that really matters to people: enabling them to get care when they want it. And, third, ensuring that we remain innovative and creative at the top of the market and that we don’t smooth out so many of the bumps that we stop seeing innovation in the market. All three of those are policy goals that we need to keep in mind.  

FH: How has the role of cost transparency in the marketplace evolved over the past few years? To what extent has the current healthcare environment impacted the way in which cost transparency is figuring into the national conversation on costs? What is the future of healthcare cost transparency?

SG: Cost transparency is a relatively new idea that is more evident in its promise than in its practice. We haven’t seen large-scale changes that have come about because of price transparency in healthcare, but neither have we seen the kind of price transparency that might drive those kinds of changes. We’ve seen some impressive results for very narrowly tailored tools like reference pricing, which has been undertaken in California around specific surgical procedures, but it’s a very small slice of the market that falls into that space, and it hasn’t caught on widely.   Cost transparency is an idea that we need to think through and develop further because it interacts with so many other things. We should be asking questions like: Transparency of which prices? Should we focus on the transparency of the underlying transaction prices that insurers negotiate with providers? Or, should the focus be on the prices that patients pay for particular services? Is this about patients containing costs by not using services because of their deductibles and cost sharing? Is it patients shopping for a provider from among those that offer either better value or worse value, and, if so, how are they going to know which is which? Is it about insurers being more aggressive negotiators in the market? There is a lot to explore around what kind of price transparency we are talking about, and we need a lot more evidence to understand what is driving those prices in the first place.  

FH: FAIR Health strives to lead as a source of independent and objective price and utilization information. How do you see FAIR Health’s role in the healthcare sector and the value of claims data in addressing the system’s current challenges? Looking to the future, what do you predict the next few years will hold for FAIR Health?

SG: It is wonderful to go around the country and talk to people about FAIR Health data and see their reactions to the availability of this extraordinary resource; people are very excited about it. From a research perspective, FAIR Health provides data that are much better than the resources that were available prior to its creation. Using FAIR Health data, we are going to be able to answer more of the kinds of questions we want to answer than was the case in the past, particularly around prices and what drives price variation, and even questions around quality and access. In addition to its production of cost information for the entire healthcare sector, FAIR Health’s reports related, for example, to new venues of care, the impact of changes in public policy and patterns of allergy diagnosis and testing are particularly fascinating. All of FAIR Health’s initiatives, whether illuminating healthcare cost and treatment variations or discovering differences in treatment protocols for opioid abuse, demonstrate its unparalleled resources and unique capabilities and are contributing to our understanding of the healthcare landscape.