The More Things Change the More They Stay the Same: Takeaways from “The State of Healthcare in the Triangle”

Bon Jovi had it right, especially when it comes to healthcare. There were few surprises for those attending this week’s Triangle Business Journal panel on the state of healthcare in the Triangle:

• • The economics of healthcare are still not working
  • Covid accelerated industry chaos that was already gaining speed
  • Fee-for-service is still unsustainable
  • Clinician staffing is still a challenge, and burnout is ever-increasing

The list goes on. And while the panelists engagingly presented the problems faced by patients, providers, and payers—along with some solutions—the most eyebrow-raising moments of the morning came from the audience.

No One is Actually Getting Paid from Value-Based Care

The commenter who raised this point noted that, while it sounds “sexy” to keep talking about value-based care, few providers and health systems are prospering. One of the most difficult challenges for providers is that it’s impossible to function simultaneously in fee-for-service (FFS) and value-based care (VBC) models. Yes, there are ways we can continue to chip away at FFS, but as the complexity of care increases, so does the complexity around FFS versus VBC, the panelists said. And unfortunately, even though our systems and technology are getting smarter, patients continue to “get less healthy.”

The key to this is data. The transition to VBC is dependent on a perfect exchange of data, and this is where things have traditionally fallen apart, said panelists. But there’s somewhat of a catch-22. Enhanced data sharing requires investment. And one panelist thinks the solution is moving more patients to value-based care—or “healthy care” programs, so that it makes financial sense to invest & create these programs—and the data infrastructure behind them—that engage patients and keep people well. The only way to make VBC economically feasible is to have a critical mass of patients in these programs, but if providers aren’t benefitting economically from these programs, there’s little incentive to move more patients into them.

The bottom line, according to the panel, is that everyone needs to make money. But without sharing data with 100% transparency, providers will always be in an adversarial relationship with payers, and that puts the breaks on value-based care.

North Carolina is Failing Women—do Payers Shoulder the Blame?

Another audience member shared a personal story of breast cancer that went undetected due to the reduced ability of both conventional mammograms and digital breast tomosynthesis (DBT, or 3D mammography) to detect tumors in dense breast tissue. A traditional mammogram can miss cancer approximately half the time in women with dense breast tissue, while at the same time, high breast density can increase the risk of developing breast cancer.

In these cases, additional screening via MRI or ultrasound can be key in detecting breast cancer—but private insurance may deny coverage for this supplemental screening. While insurance coverage depends on several factors, and one of those factors is whether or not a state requires coverage for supplemental screening.

Approximately 23 states plus the District of Columbia have legislated increased commercial coverage for supplemental breast cancer screening, and North Carolina is not one of them (though Medicaid does cover supplemental screenings).

A state-level solution has been introduced with the Diagnostic Imaging Bill (NC House Bill 560) that is intended to provide health coverage parity for breast cancer diagnostic imaging and supplemental screenings. The goal is to allow health care providers determine the appropriate examinations to evaluate breast abnormalities. This bill has passed in the House (116-0), and on May 2, 2023 it was referred to Senate, where it waits.

This could also be remedied by the Find It Early Act, introduced on May 5, 2023 in the U.S. House of Representatives. The act mandates coverage for medically necessary supplemental imaging with no out-of-pocket cost. The bill was referred on May 26, 2023 to the House Subcommittee on Health where it remains, according to congress.gov. It has a less than 1% chance of passing, according to govtrack.us.

The Bottom Line

As the panel wound down, an observation was made that we need to renew focus on one key, simple thing that is necessary for good healthcare—the relationship between the patient and their provider. Unfortunately, the chaos continues to get in the way.