Ellen Andrews has served on over a dozen health policy committees in Connecticut. If it were up to her, they would all be eliminated.
“The best thing Connecticut could do is do away with all its committees and boards and task forces,” said Andrews.
Andrews has been the director of the non-profit Connecticut Health Policy Project, which publishes research and briefs about Connecticut healthcare policy, since it was founded in 1999. She also serves on the state Medical Assistance Program Oversight Council, which advises on Connecticut’s Medicare Program, and the Health Care Cabinet for the state Office of Health Strategy, which advises state officials on federal health reform policies.
In her 25 years of experience, Andrews said she’s watched as committees have taken on a different tone. What were once places for lively discussion about health care policy presided over by a diverse group of members — doctors, individual consumers, appointments from both the Democrats and Republicans — over the last two administrations have been filled instead with people with fixed ideas of what the outcomes should be.
Andrews said that she has also noticed a conspicuous lack of advocates for ordinary consumers.
The result, said Andrews, is higher copays and high deductibles — things that put pressure on consumers to choose between their wallets and their physical health. Other policies, she said, pressure doctors to keep down the costs of care — incentivizing them, for example, to prescribe less expensive drugs in cases where a more expensive one might have fewer side effects.
“As a consumer advocate, if we were spending, you know, 20% of our GDP on good quality care, I would not have a problem with that,” she said. “I’m just disturbed that the quality isn’t there and there’s so much waste.”
A legislative role?
With the Democratic proposal for a public option and the Republican reinsurance plan, health care promises to be a topic that is both central and contentious in the January legislative session.
But Andrews expressed doubt that either plan would make it through the legislature, largely because both rely on taxpayer dollars.
In addition, she said, by focusing on health insurance costs, rather than on the cost of care, both solutions miss the real problem.
That’s not to say that Andrews thinks there’s nothing the legislature can do. In fact, she said the state has a duty to make sure that its citizens receive quality medical care.
“The opportunity cost here of just another year where we don’t do anything … means millions and millions of dollars that consumers are paying out that they shouldn’t be,” warned Andrews.
Capping the cost of prescription drugs
According to Andrews, the first thing that has to be addressed is the cost of prescription drugs. She praised the legislation passed in the July Special Session capping the cost of insulin. However, she said that insulin is not the only offender, Humira, a drug used to treat autoimmune disorders like Crohn’s Disease, is another drug she considers to be wildly overpriced.
Andrews recommended that the legislature adopt a policy similar to Massachusetts, which places an 80 percent tax on drug companies for the sale of drugs that are determined to be unnecessarily expensive. She said that Connecticut could use the reports produced by the Institute for Clinical and Economic Review, of which Andrews is a member. These reports, in which experts evaluate price increases of certain important drugs, are a resource that the state can obtain for free.
Another option would be for Connecticut to create its own committee to evaluate drug prices. Massachusetts has its own commission to evaluate drug prices, which is staffed by the state’s Health Policy Commission. Andrews, however, said she doesn’t think that’s the best option for Connecticut — she said there is too much potential for conflicts of interest.
“They actually have trouble getting experts who have never worked for a drug company and don’t own stock in drug companies in Connecticut,” she said.
Andrews said that, ideally, representatives from insurance companies and drug companies should not be allowed to be voting members on committees. They should be able to give input, she said, but they should not be involved in the decision making process. Instead, she said, Connecticut goes out of its way to include representatives from these different sectors.
“Surprise, surprise, you get exactly what you started with — nothing changes — because you’re putting all the people who win from the current system around the table,” she said.
Andrews sees industry consolidation as another challenge to high quality, affordable health care — a decrease in competition, she said, allows corporations to set whatever prices they want. And in contrast to what these larger corporations claim, according to Andrews, having all physicians under a large umbrella organization does not improve the care available to patients, in fact, it takes away patients’ ability to choose from a variety of options.
“They always say there’s going to be economies of scale, and so they’ll be able to get gloves and whatever, beds, at better prices,” she said. “And maybe they do, but it has not lowered prices — it increases them.”
Andrews said she’d like to see a moratorium on mergers, but she conceded that it wouldn’t necessarily do much in certain areas of Connecticut, particularly the southeast, where nearly all private practices have already been bought up by larger hospital chains. Still, she suggested that a moratorium could act as a symbol that Connecticut was no longer willing to turn a blind eye to the way that large corporations were buying up independent practices.
Even if mergers can’t be prevented or broken up, Andrews said there are certain things that can be done to create a more competitive marketplace.
Despite her stated rejection of committees, Andrews suggested the formation of a bi-partisan task force to explore options to increase competition. These could include eliminating non-compete clauses in contracts, which make it much more difficult for physicians to leave the hospitals or groups they are working at if they are unhappy with the situation.
She also endorsed a proposal by State Sen. Martin Looney, D-New Haven, which would require the state to issue a “Certificate of Need” for corporate takeovers of private medical practices. His proposal would also change the current position of the state toward these mergers from a “presumption of approval” to a neutral consideration of these practices. Andrews said that out of 74 Certificates of Need issued last year, all but three were approved.
“The state can make changes,” she said. “Antitrust laws are enforced at the state level … the state simply can’t throw up their hands and say, ‘Well, there’s nothing we can do.’”
Transparency and moving ahead
Andrews said that transparency around healthcare is critical, especially in a system known for being both opaque and complex. She said that neither the state insurance exchange nor private companies are required to disclose basic information about how many people are covered and the cost of that coverage. If the state were to adopt a public option or a reinsurance program, she said, there would need to be someone monitoring it to hold the systems accountable.
Nor is there any information about how much procedures cost, although Andrews said this might be less important for patients, who, she said, don’t really tend to shop around for the best price for healthcare. Even if they did, she said, the additional fees and costs that come with any procedure make it almost impossible to make accurate comparisons.
Transparency around the cost of procedures, Andrews said, would be useful for doctors, who could compare rates. Andrews did admit that this sometimes backfires – she knew of at least one instance where doctors discovered they were being paid less than their counterparts and ended up charging consumers more. And if a consumer believed he or she wasn’t getting the best treatment and wanted to file a complaint, she said, most people wouldn’t have any idea how to begin, or even that they had the right to do so.
Andrews has other concerns as well.
She said that the idea of cost-capping, which the Office of Health Strategy has been promoting, could open up the door for hospitals and insurers to eliminate services that patients really needed in the name of tightening a budget.
Andrews said she was concerned that the new Health Information Exchange could severely compromise the privacy of patient information. She also said that telehealth should not necessarily receive a reimbursement equal to an office visit, out of concern that it will incentivize providers to schedule telehealth consultations for individuals who might be in need of an in-person appointment.
If the pandemic has taught us anything, said Andrews, it’s the value of forward thinking. She said that health care needs to be the recipient of continuous investment if patients are going to get the best care.
“We really need to be making investments in things that…[are]not an emergency today,” she said. “We have been just cutting back and starving public health … and now we know what the results of that are.”