State Health Policy Resources for the COVID-19 Era

By |2020-03-26T17:05:27+00:00March 26th, 2020|Health Care Trends, Medicaid, Medicare, State Health Initiatives, Uncategorized|

State Health Policy Resources for the COVID-19 Era

M2’s focus has always been state health policy, and right now, WOW, there’s a lot of action at the state level! We pulled together a list of resources for anyone wanting to take a closer look at state actions and/or policies by state. See our list below and feel free to share additional state level policy resources you are finding useful.

Is this the year we finally talk about all health care costs?

By |2020-01-13T18:48:48+00:00January 13th, 2020|Health care spending, Health Care Trends, Out-of-pocket spending, Providers, Uncategorized|

Is this the year we finally talk about all health care costs?

While patients, families and employers have been talking about rising (and in many cases, unmanageable) health care costs for years, it appears researchers finally may be getting on board with the issue as well.

Three notable reports came out in the past few weeks comparing what the U.S. spends on health care to other countries.

The U.S. System Costs More to Administer than Other Countries

The Annals of Internal Medicine published a study on January 7, putting new numbers to an old question. How much does the U.S. spend on the administration of health care? About four times more than Canada spends, evidently. Administering care is much cheaper in Canada, for example, because there are standardized forms and processes for providers, facilities, and families to use to access and pay for care. The study authors estimate $600 billion a year is spent in the U.S. on administrative bureaucracy instead of clinical care. On a per person basis, this amounts to $844 spent per person for health insurance plan overhead in the U.S., versus $146 per person in Canada.

The U.S. System Pays Physicians More than Other Countries Do

It’s not just health plan administrative costs that drives U.S. spending higher, though as we have written before, streamlining forms and processes seems like an obvious place to start cutting costs. The U.S. also pays physicians more than other countries do. Anne Case and Angus Deaton – the economists who called attention to the rising number of “deaths of despair” in 2015 (and won a Nobel prize for their work that year) made headlines this week at the annual American Economic Association’s annual meeting when they said physicians are driving U.S. health care costs:

“We have half as many physicians per head as most European countries, yet they get paid two times as much, on average…” says Deaton. “Physicians are a giant rent-seeking conspiracy that’s taking money away from the rest of us, and yet everybody loves physicians. You can’t touch them.” (source: Washington Post).

Is this a Good Thing or a Bad Thing? (I ask in jest…)

Maybe the Internet coordinated these news reports, but the same day the Case/Deaton comments came out, several news outlets reported: Health care positions top 2020 list of best (paying) jobs! Indeed, 12 of the top 20 best paying jobs for 2020 are in health care. Here is the list from US News and World Report:

Best-Paying Jobs

  1. Anesthesiologist
  2. Surgeon
  3. Oral and Maxillofacial Surgeon
  4. Obstetrician and Gynecologist
  5. Orthodontist
  6. Psychiatrist
  7. Physician
  8. Prosthodontist
  9. Pediatrician
  10. Dentist
  11. Nurse Anesthetist
  12. Petroleum Engineer
  13. IT Manager
  14. Podiatrist
  15. Marketing Manager
  16. Financial Manager
  17. Pilot
  18. Lawyer
  19. Sales Manager
  20. Business Operations Manager

It’s good to see more attention being paid to costs, and it’s especially good to see research and data behind the alarming stories. We all know that health care costs are going up but if we really want to do something about it, we have to look at ALL health care costs. This kind of data is the first step toward policy making; let’s see what happens next.

In 2020, Patients Will Need to Be More Demanding

By |2019-12-27T12:25:53+00:00December 27th, 2019|Health Care Trends, Patients, Uncategorized|

In 2020, Patients Will Need to Be More Demanding

One of the last sessions I did as a panelist this year was part of a conference for patient groups across the country about patient rights related to transparency and access. My panel was asked to discuss current and proposed policies related to health care transparency and access to care, so I noted:

  1. Various state efforts to help patients get more information, especially about hospital prices;
  2. The November 2019 Department of Health and Human Services, the Department of Labor, and the Department of the Treasury’s proposed rule to improve transparency on the price consumers pay for certain health care services; and
  3. The importance of advocating for what the National Health Council calls Patient Factors of Value as payers rely more on so-called assessments of health care “value” from third-parties, such as the Institute for Clinical and Economic Review (ICER).

As I heard the audience questions, though, I was reminded of the limitations of policy making. Yes, policies should support patient transparency and access. No question. But perhaps more important is changing the way we act.

To put it bluntly, patients are going to need to be much more demanding.

And not just patients, but also anyone who supports patients, whether it be family members, friends, health care providers, employers, administrators, or legislators, will have to be much more demanding.

This means patients can’t wait for information to be provided by the health plan, hospital, or specialist.

We need to ask for information we want at every appointment, and before an appointment, as well.

We need to ask for information on cost-sharing. On treatment alternatives. On what evidence exists for the treatments. On how to get a second opinion about the diagnosis.

We need to ask about what supports are available during and after treatments.

We need to ask: What didn’t I ask? Who else should I talk to?

Making various kinds of health care information available may prove to be useful, but real change will need to be driven by patients and their supporters. Patient rights are essential, but in 2020 (and beyond), patients, and all of us who support them, will have to be much more demanding.

Health care costs: What’s the real story?

By |2019-11-13T16:19:34+00:00November 13th, 2019|Health care spending, Health Care Trends, Health Plans, Hospitals, Insurance, Providers, Uncategorized|

Health care costs: What’s the real story?

As I travel around the country talking to state legislators and health care leaders, questions about health care costs are usually at the top of their lists. The first request they make is for credible, public sources of information they can use to help inform their policy decision making.

Two slides I frequently use in presentations receive the highest engagement. My informal measurements of engagement are people in the audience taking pictures of the screen when the slide appears, and comments such as, “This is incredibly helpful” or “I haven’t seen it presented like this before.”

The first slide is a graphic (see below) from the Peterson-Kaiser Health System Tracker and shows how cost-sharing requirements, especially in the form of deductibles, have outpaced wage growth.

The second slide I created because the information is harder to find than you’d expect. Notably, the information is out there, but it is buried in data sets, not in a visual that can be quickly understood and easily shared.

Combining information on health expenditure data and historical inflation information the graphic (see below) shows the annual change in spending for the three most talked about categories of health care, hospitals, physician services, and prescription drugs, as well as general inflation for the last 10 years.

If you live and breathe health policy, these visuals may be no surprise to you. State legislators, on the other hand, are asked to be experts in a mindboggling array of issues. They rely on their staff and the internet to understand these issues, but what if the internet doesn’t serve up the info they need?

M2 aims to be a reliable source of information on all things health policy, and we strive to make complicated information from a multitude of sources more concise and comprehensible. Hopefully, the slides we share prove useful to you. Let us know what you think!

Can Price Transparency in Health Care Really Lower Costs?

By |2019-08-21T14:53:39+00:00August 20th, 2019|Health care spending, Health Care Trends, Hospitals, Insurance, Out-of-pocket spending, Physician-patient communication, Providers, Reimbursement, Uncategorized|

Can Price Transparency in Health Care Really Lower Costs?

Telling patients what they will pay for their health care services is a key stepping stone to more efficient use of health care dollars. Consumers, employers, payers, and the system as a whole would likely benefit if the true cost to the patient were made available before a patient receives a health care service or product.

Several states already have laws on the books requiring health care providers to make at least some price information available on at least some procedures. Some states also run centralized databases where different payers report what they get paid for different services. Additionally, the federal government requires hospitals to post a list of standard charges on the internet.

The Trump Administration wants providers to further expand the price and quality information to consumers, and issued an Executive Order (EO) on Improving Price and Quality Transparency in American Healthcare to Put Patients First in late June. The order aims to help consumers make “well-informed decisions” and expand transparency efforts that provide information “which patients can research and compare before making informed choices based on price and quality.”

More specifically, the EO directs the U.S. Department of Health and Human Services (HHS) to require hospitals to publish negotiated rates in a searchable, consumer-friendly format for 300 “shoppable” services.

You Can Shop if You Want To

Consumers are being asked to make more of these decisions on their own, as we’ve described in previous posts. My home state of Colorado has a shopping tool like the one the EO has in mind. It took me less than a minute to get the result below from the Colorado Center for Improving Value in Health Care (CIVHC) for an MRI scan of a leg joint within 15 miles of my ZIP code:

Shop for Health Care Services – MRI Scan, Leg joint (CPT 73721)

Seems pretty obvious that while the closest option, seven miles away, is Centura Health St Anthony Hospital, they would charge me $510 for the scan. If I drive another five miles, I would only have to pay $150 at Denver Health Medical Center.

“Shoppable,” but Perhaps Not “Buyable”

According to the Health Care Cost Institute (HCCI), “For a health care service to be ‘shoppable’, it must be a common health care service that can be researched (“shopped”) in advance; multiple providers of that service must be available in a market (i.e., competition); and sufficient data about the prices and quality of services must be available.” HCCI estimates that approximately half of out-of-pocket spending is spent on “shoppable ambulatory doctor services.”

The problem is, you might be able to research and compare certain services with upgraded information, thus improving your shopping experience, but you might really struggle to buy the service that is lower in cost.

Using the example of lower-limb MRIs, a 2018 study titled Are Health Care Services Shoppable? Evidence from the Consumption of Lower-Limb MRI Scans found that people typically drive by multiple lower-priced providers to get to their final treatment location. Why? Because that is where the patient’s referring provider sends them. The study shows “the influence of referring physicians is dramatically greater than the influence of patient cost-sharing or patients’ home ZIP code fixed effects.”

In particular, “physicians who are vertically integrated with hospitals are more likely to refer patients to hospitals for lower-limb MRI scans.” We’ve written previously about how costs vary dramatically by site of care. That also means patient cost-sharing varies. We are asked to pay more out-of-pocket for a service we could get elsewhere. But that would mean 1) shopping and 2) acting against the advice of a provider. Not impossible tasks, but difficult for sure.

Increased transparency means you can shop for services, but that is only half of the problem. Yes, it is important to have price and quality information. If the problem were a technical one, more information would lead to different decision making. But in fact, changing the way a consumer selects a health care service – even a “shoppable” service – is an adaptive problem. That is, it requires a change in the way people think, prioritize, and behave.

Additional information on quality and price is definitely necessary, but if I drive by two Centura Health facilities with lower cost MRIs to get to the HealthOne facility my referring provider recommended, I would also need some encouragement, at least, to go against my physician’s recommendation.

It looks like we health policy types have more work to do.

Have we passed peak health care disruption?

By |2019-07-08T21:03:06+00:00July 8th, 2019|Health Care Trends, Health Reform, Innovation, Uncategorized|

Have we passed peak health care disruption?

Disrupting health care has been a hot topic the past few years, but it seems to me we have passed peak health care disruption and firms are now having to roll up their sleeves to do the boring, difficult work of creating incremental change.

The high point of disruption in health care (see chart below) looks to be the announcement January 30, 2018 from Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. of a health care joint venture to “address healthcare for their U.S. employees.

What has happened related to that partnership in the last 18 months is the naming of the entity (Haven), some prominent hires (Dr. Atul Gawande), and some key staff departures (Jack Stoddard).

But there have been some notable smaller steps from two of the three Haven entities that signal feasibility and immediate impact are stronger drivers than disruption. While policy types may be interested in wholesale transformation, the business of digital health is concentrated on more immediate change.

Right after the Haven announcement, Amazon bought PillPack, an online pharmacy and platform that helps manage patient data. Last month, JPMorgan Chase & Co. bought InstaMed, adding health care payment services to the bank’s existing service offerings in wholesale payments. Knowing more about your customer and serving them better, just like in any other business, seems to be where health care companies are focused.

These kinds of digital health deals may be the wave of the future, according to RockHealth’s 2019 Midyear Digital Health Market Update. Their report (see chart below) shows a steady amount of digital health investing year-over-year, but an increasing average deal amount.

Perhaps more importantly, acquisition by non-health care companies is proving to be an increasingly likely exit ramp for digital health investors, as the PillPack and InstaMed deals exemplify. Providers and non-health care companies are stepping up their acquisitions of digital health ventures, as the chart below shows.

The next step in health care might be smaller than the word “disruption” implies. Over the past few years, health care has proven to be more complex than many tech companies and policymakers have thought. RockHealth quotes David Kim, Managing Director of DigiTx Partners, as saying: Big tech companies “are likely to acquire technologies and companies with expertise and domain knowledge that allow them to take that next step to health care without just diving in blindly headfirst.”

If disruption equates to diving in blindly headfirst, I agree. Health care change going forward is going to be data-fixated, consumer-focused, and incremental.

“Medicare-for-All” Understood as Lower Premiums for Me?

By |2019-05-07T20:39:01+00:00May 7th, 2019|Health care spending, Health Care Trends, Health Plans, Health Reform, Insurance, Medicare, Medicare For All, Out-of-pocket spending, Uncategorized|

“Medicare-for-All” Understood as Lower Premiums for Me?

Proposals for Medicare-for-All, or more accurately, universal health coverage, are being introduced by both Congress and state legislatures at a rapid pace (see this useful interactive tool, The Many Varieties of Universal Coverage from The Commonwealth Fund). While policy types argue over how such a plan would be funded and how to set reimbursement rates for providers, and Wall Street frets about what single payer health coverage would do to health insurance companies, state legislators and regular people seem to have a different perspective. In my many conversations with people across the country about the idea of “Medicare-for-All,” I have found it striking how often people say they favor such an approach because they want lower health insurance premiums.

I think we may have a language problem. When health policy people hear “Medicare-for-All”, they think “change the health care delivery and insurance infrastructure from employer contributions to taxpayer contributions,” but maybe when regular people say “Medicare-for-All”, they mean “please find a way to lower my premiums”. The Kaiser Family Foundation Health Tracking Poll conducted in early January hints at the importance of lower premiums as a reason to support “Medicare-for-All” type proposals. As shown in the figure below, nearly 50% of people polled strongly favored proposals that allow people between 50 and 64 years of age to buy in to Medicare, or allow people to buy in to Medicaid, or create a plan like Medicare that is available to anyone. Getting insurance from a single government plan is strongly favored by only 34% of respondents.

These “buy-in” proposals may be gaining in popularity as people lose access to employer-sponsored insurance. Here is the math: “if the coverage rate for employer-sponsored insurance was the same in 2017 as it was in 1999 (67.3%), almost 24 million (or 23.8 million) additional people would be covered through an employer plan in 2017.”

It’s easy to understand why people would focus on lower health care premiums; rising premiums are having a big impact on household incomes. As fewer people are receiving health insurance through their employer, they are also being exposed to higher costs for health care premiums. We pulled recent information on employer and worker contributions for health insurance, the average national premium for a person earning just over 400% of FPL ($49,000) to buy a health plan on the ACA Exchange at various ages, and Medicare premiums. We then created a rough comparison chart of what premiums an individual might have to pay for health insurance based on how they accessed coverage. Below is what we found:

Notably, the average annual premium for employer-sponsored coverage of an individual was about $6,900 last year. But employees usually paid just 18% of that amount. For people who may have been covered by their employer for years, and then have to buy insurance in the ACA Exchange, the loss of that employer-sponsored contribution to their health insurance coverage could be quite a shock.

It’s a catchy phrase and easy to hashtag in social media, but is the appeal of Medicare-for-All driven largely by the hope that a person’s premiums will be lower? Is Medicare-for-All the best or only way to achieve lower premiums? As with all policy issues, we should probably start with the key question, “what problem are we trying to solve” and then go from there, always checking to see that we are, in fact, addressing the problem we are trying to solve with a workable solution.

Small Step Service Design Thinking – The Case of the Nurse Practitioner in the Fire Department

By |2019-03-22T14:05:22+00:00March 20th, 2019|Health Care Trends, Innovation, Providers, Uncategorized|

Small Step Service Design Thinking – The Case of the Nurse Practitioner in the Fire Department

As we blogged a couple weeks ago, M2 authored a chapter entitled “Using Small Step Service Design Thinking to Create and Implement Services that Improve Patient Care,” in Service Design and Service Thinking in Healthcare and Hospital Management published by Springer. Today we share highlights from the second case study we feature in the chapter.

Fire department or health care provider?

When most of us think of health care organizations, we tend to think of our own experience, perhaps our physician’s office building, or a Kaiser-like integrated health system campus. But the fragmented U.S. health care system also relies on a “safety net” that includes community clinics, public hospitals, local health departments, and the emergency medical system (EMS).

As in the rest of the nation, in Los Angeles, (the second largest city in the U.S with 4+ million people) the 9-1-1 system serves as a safety net for health and social issues in the community. Perhaps surprisingly, the Los Angeles Fire Department (LAFD) is a key component of the city’s health care safety net. “The LAFD is the largest provider of acute, unscheduled medical care in Los Angeles,” and of the more than 425,000 annual calls for service, 85% are for medical services, not fire.

What would fire response look like if you put the patient first?

In 2016, Dr. Marc Eckstein, medical director of the LAFD, led the development and launch of the nurse practitioner response unit (NPRU) pilot project. A great example of using small step service design thinking, the creation of the NPRU was driven by a deep understanding of the people the LAFD serves. Leaders of the NPRU explained their thinking in creating the healthcare innovation: “This challenge naturally summons the need to better understand who our clients really are, and how we can work with other community partners to more collectively match our collective response to each client.”

What the team understood from years in the field talking and working with residents of Los Angeles County was that community members trusted the LAFD and that is why they called. Further, the team recognized, “for those with lower socioeconomic status, the fire department is their only means of access to healthcare, and has been for a number of years.” Additionally, Terrance Ito, DNP, FNP-BC, the LAFD EMS Nurse Practitioner supervisor explained, “many of them lacked health insurance for a number of years—and having recently become insured, we’ve found that they’re having difficulty with healthcare navigation.”

Meeting patients where they are – literally and figuratively

The NPRU model is designed to intervene with patients as early as possible in the course of emergency care, in part by focusing on what are called “prehospital” encounters. In a report prepared for the California HealthCare Foundation and California Emergency Medical Services Authority by Dr. Kenneth Kizer and his colleagues, prehospital services can include transporting patients who don’t need emergency care to non-emergency department (ED) locations, refer or release individuals at the scene of emergency response, and/or addressing the needs of frequent 9-1-1 callers (or ED visitors) “by helping them access primary care and other social services.”

The NPRU is a converted ambulance that is staffed by a range of emergency professionals including firefighters, paramedics, and nurse practitioners. The missions of the NPRU include providing mobile urgent care at the scene of an emergency call, and comprehensively assessing frequent users of emergency services, then connecting them to care or social services, as necessary.

A small step service design change, the NPRU allows patients to be served where the ambulance goes – often to a person’s home after he or she has called 9-1-1, instead of transporting the patient with little thought to where the patient can best be served. Notably, in February 2019, the Centers for Medicare and Medicaid Innovation announced a new payment model that will support exactly this kind of health service innovation. The Emergency Triage, Treat and Transport (ET3) Model will allow providers serving Medicare beneficiaries to be reimbursed not only for ambulance services to hospitals, but also for transport to lower level sites of care, for example a physician’s office or urgent care clinic. The ET3 Model would also allow reimbursement for models such as the LAFD NPRU that treat “in place with a qualified health care practitioner, either on the scene or connected using telehealth.”

Our book chapter on using small step service design thinking in health care used two case studies to highlight not just theories, but models that have been tested and proven effective in improving patient care. These models mirror what we hear from patients in our client work – ask us what we think would improve patient care and create policy accordingly. This simple idea drives our work every day. We hope you will consider it in your health care policy work as well.

We Pay for What We Value. Guess What We Value in the U.S. Health Care System?

By |2019-02-04T17:27:13+00:00February 1st, 2019|Health care spending, Health Care Trends, Hospitals, Insurance, Providers, Uncategorized, What do we pay for and why|

We Pay for What We Value. Guess What We Value in the U.S. Health Care System?

People often ask what the difference is between the United States and other health care systems. Health Affairs recently published a helpful piece focused on comparing costs entitled “It’s Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt” by Gerard F. Anderson of Johns Hopkins Bloomberg School of Public Health, Peter Hussey, a VP at RAND Corporation in Boston, and Varduhi Petrosyan, a professor and dean in the Turpanjian School of Public Health, American University of Armenia, in Yerevan. The article is an update of a similar one they published back in 2003, along with Uwe E. Reinhardt, who was the James Madison Professor of Political Economy at the Woodrow Wilson School of Public and International Affairs, Princeton University, until his death in November 2017. The authors compare the health care costs, accessibility, spending growth rates, and other fees in OECD countries.

Notably, there is no concise chart in the article, showing the side-by-side of this information – so we made one! We also calculated a multiple, to see how much more (or less, but usually more) the U.S. spends compared to the median of the OECD countries.

In the chart below, we tried to focus on the main categories of health care costs – health insurance administrative costs, hospital care, physician salaries, nurse salaries and pharmaceutical spending. Interestingly, the information needed for a comparison across countries and categories was not always available in the Health Affairs article. This highlights a pretty big problem with health care data – researchers often say that it’s hard to compare inputs across countries because of their different systems and economies, so they just don’t. This means we don’t actually know for sure how these costs compare to each other.

You may notice the huge difference in per capita health insurance administrative costs. The fact that the U.S. spends almost 8 times as much as the median of OECD countries on health insurance administrative costs (and not actual health care) is rarely a focus of health system policy change, though it is well-known:

“The next-highest-spending country after the US (Switzerland) had administrative costs of only $280. In 2017 Steffie Woolhandler and David Himmelstein [Commonwealth Fund] estimated that the US would save about $617 billion (about 20% of its total health spending) if it moved to a single-payer system.”

We have written about standardizing a single set of forms before. Maybe this is a good place to start addressing health care costs in the U.S.?

Another area of high cost in the U.S. compared to other countries is hospital and health care providers. According to the Health Affairs article, all of the inputs for hospital care – including “health care workers’ salaries, medical equipment, and pharmaceutical and other supplies – are much more expensive than in other countries.”

Why are health care provider costs higher in the U.S.? In part because the allocation of physicians in the U.S. is different from other OECD countries, and skews to more expensive care: the U.S. has the lowest percentage of general physicians relative to specialists of OECD countries.

Making changes seems as easy as the U.S. looking to a country that seems to have lower health care costs and “copying” what they do. But these researchers did this same analysis in 2003 based on 2000 data and now, nearly 20 years later, they found the relative rankings of the countries to be about the same for most indicators. Health care costs are different across countries because health care systems are different across countries. And of course, systems are different across countries because values are different.

Based on what the U.S. spends in different health care categories compared to other countries, we seem to really value health insurance administrative costs. Now we know.

Here’s a health policy idea, let’s listen to patients

By |2019-01-24T15:19:50+00:00January 23rd, 2019|Health Care Trends, Innovation, Uncategorized, What do we pay for and why|

Here’s a health policy idea, let’s listen to patients

Earlier this month I was a presenter and leader of a panel session at the Washington State of Reform Health Policy Conference in Seattle titled, “A Policy Framework for New Medicine.” The other two panelists and I were asked to present our points-of-view about policy related to “personalized medicine, miracle drugs, and genome-specific therapies.” The other two panelists were gene therapy patients. Ashanthi DeSilva is the first person in the world to undergo an approved gene therapy, which she did at the age of 4 in 1990. Toby Willis was “the first adult to undergo the first gene therapy approved in the U.S. for treatment of an inherited disease,” in March 2018.

Gene therapy is a topic of particular interest to me, naturally because of the work that I do, but also because I wrote my thesis to complete an M.A. in Philosophy at Boston College on the ethical use of gene therapy, in 1994. Those were the early days of gene therapy as a practical treatment, and I encountered a great deal of resistance for my thesis proposal from the hallowed halls of the esteemed Jesuit institution. My advisors were just not convinced there was any real-world application for gene therapy, and therefore they didn’t see the value in developing a framework for navigating the ethical considerations that I was sure were on the cusp of driving innovative patient care. What an incredible experience for me, then, to meet the woman who had undergone the world’s first gene therapy trial as a young child in roughly the same time period that I was pushing for approval from the chair of the philosophy department to start a conversation on how to decide who should receive (and for what reasons) gene therapies.

Both Ms. DeSilva and Mr. Willis are remarkable people and they were able to shine a light on the policy problems that still exist decades after gene therapy was first used to treat a patient. For example, Ms. DeSilva must still argue with her insurance company to have her ancillary medications approved because they are subject to prior authorization requirements despite the fact that she needs them because of her primary diagnosis – and will likely need them for the rest of her life. Mr. Willis’s policy story focused on the core questions before the group: Should we pay for innovative treatment? For whom? Under what circumstances? And, of course, who should pay? Individuals? Employers? Insurers? Taxpayers?

These sessions can sometimes be dry presentations where speakers do their thing without any regard for the audience. What happened at this session was different. It was a free flowing discussion that used the panelists as touchpoints, but drew out the expertise and ideas of audience members – including a health plan, a specialist provider, a policymaker, and pharmaceutical manufacturer. Some policy concepts offered were easily agreed upon, for example, trying to spread risk across a broader pool of people or spreading the costs of treatments over time. But I was the most impressed with the policy ideas offered by the patients in the room who were recipients of life-changing treatment. The ideas were at once simple, and nearly impossible. To close the session I asked the other panelists to give one recommendation for people in the audience to do when they left the room.

Ms. De Silva recommended that when thinking about health care policy, we should all try to think of someone besides ourselves.

Mr. Willis, who claimed not to be a policy expert, deftly explained what seems to be the core of the problem with the U.S health care system today. He said, “the system treats health plans as the customer, but I think patients should be the customer.”

So, as we begin an already busy health care policy 2019, I will be trying to heed this great advice. Maybe policymakers will, too.