To mark the 25th anniversary of the journal, each issue in 2020 will include an interview with a health care thought leader. The October issue features a conversation with Kavita K. Patel, MD, MS, nonresident fellow at The Brookings Institution and editorial board member of AJMC®.
Am J Manag Care. 2020;26(10):421-422. https://doi.org/10.37765/ajmc.2020.88499
AJMC®: Something that has been noted throughout this 25th anniversary interview series is that Americans probably don’t have the will or the capacity to do anything different in terms of lowering the cost of care or widening access to care and that institutions are slow to adopt change. Thinking about the coronavirus disease 2019 (COVID-19) pandemic, do you think that will continue to be the case going forward, or do you think there’s a chance that this could be a tipping point for public health?
Patel: I definitely think it’s a tipping point. There’s no question that something material and hopefully positive will come out of this, but I think you’re asking kind of the more nuanced question, which is exactly how much of a difference will that make? So, yes, I do think that we’re at a tipping point; something will change. But no, I do not think that [it will be permanent]. Let’s say we fast forward a year and there’s a very safe and effective set of vaccines, and we get coronavirus cases down to 100 a day, something that seems reasonable. I think that then, people will unfortunately kind of fall back into old habits, and that includes the health care system.
I think that that will only perpetuate some of the very problems that we’ve seen come out during COVID-19. The only place where I think that that’s not going to necessarily be the case is public health infrastructure. Most county and state public health departments are the first ones to get attacked on the budget side, and I think now that we’ve had such a dramatic pandemic, they will not be the first ones to get cut. Now will that last long? I don’t know. But I think that certainly reinvesting in and rethinking public health infrastructure will be a high priority for everyone.
AJMC®: One change that some people have predicted is an accelerated shift to value-based care and an increased focus on risk. In discussing the health care system, we saw that providers that were only in fee-for-service arrangements really got slammed. Do you think that could also change with an accelerated shift, or could things get in the way of that transition?
Patel: I think it’s going to change but not for the reasons that we think it might change; it’s not because of COVID-19 and what you just cited around [how] fee-for-service providers got slammed and the hardest-hit small practices, etc. I think it’ll change because of Medicare Advantage, and if you look kind of on the complement, the practices that did well were the ones that were in capitated arrangements. You can call them risk- or value-based arrangements, but they were largely like Medicare Advantage, capitated-type arrangements. And I think because Medicare Advantage will grow and because managed Medicaid is so large, that will almost become a force function. It’s not because you’re going to see this rush from fee-for-service into alternative payment models, the way some of us, including people like me, thought we would have 10 years ago, but I guess it’s going to be because the payers are not going to pay for it. And that includes Medicare, because Medicare Advantage, if anything, takes people out of that fee-for-service treadmill. So, if you call Medicare Advantage or Medicaid managed care “value,” then yes, you’re right. I think there will be a kind of an acceleration, but I think of it more as there are some insurance-based structural elements that just make the move away from fee-for-service easier. I’m not sure if it’s value. That’s probably the politically correct way of saying it.
AJMC®: Speaking of politically correct, as we’re getting closer to the election, one of the big changes the current administration made is with Medicaid work requirements. If there is a change in the administration next year and a new one comes in, what do you think would be a priority in Medicaid? Would it be a huge convoluted process to unroll that?
Patel: Yes, a priority would be to unroll that, but it’s easier. It’s definitely doable. A Biden administration would 100% do it. Getting it out? The states have decided to take it up. Basically, CMS just made it easier to put in work requirements. It’s not like Medicare or CMS actually said that all states must do this, but they basically did what’s called a waiver template and guidance and notification. You would expect a Biden CMS to completely undo that, and maybe the part that would be a little bit harder is how do you get states like Indiana, for example—where [CMS] Administrator [Seema] Verma came from, where she helped to set up some of the Medicaid program—that wanted to do this on their own, anyway, to undo that? You’re going to have to override it with some overwhelming incentives: money, basically. And I don’t know if states would take that. If a state was kind of on the bubble and didn’t want to do work requirements and felt like they were getting, quote, pressure from the Trump administration, maybe that could be undone. My fear is that Biden will definitely make actions to undo it, but if the states have already adopted it, and they don’t feel like it’s been harmful, and the legislatures and governors in those states are the same political party, I don’t know what would motivate them to undo it, so I think it will be harder. But yes, I would expect a Biden administration to not just [undo] work requirements, but to put out a series of those same kinds of guidances and notifications that actually encourage expansion of Medicaid and to do some of the things that I think the Obama administration started, where they did quality measure harmonization, accountable care organizations. You’ll see some of those same familiar themes probably continued.
AJMC®: In your mind, what have been some of the standout differences between the expansion states and the nonexpansion states in terms of population health in the Medicaid population?
Patel: I think that expansion states realized that they, in addition to the expansion, needed to really embrace what I think most of us would roughly call delivery system reforms. California serves as a model for a lot of those states to some degree, where they focus on what’s called whole-person care or whole person–centered care. It’s what they call, in Medicaid speak, Money Follows the Person—you try to think about what’s the most comprehensive care you need to give to somebody, and then all the parts of Medicaid that are confusing and somewhat siloed and complicated, and you try to reorganize them to make that whole-person care achievable. I think expansion states have tried to do that. Expansion states like Louisiana, for example, really tried to also focus on some of the cost drivers, pharmaceuticals being one of them. As for the nonexpansion states, I’m from Texas, a nonexpansion state, and Texas actually did try to do some delivery system reforms, but [the reforms] haven’t really gotten the traction that they have in other states. Candidly, Medicaid in those nonexpansion states is still kind of what I would think of as the old Medicaid from a decade-plus ago, from before the Affordable Care Act (ACA). It’s much less managed care, or even when it is managed care, many of the providers really still function almost like fee-for-service doctors. There’s an element in the nonexpansion states where there’s, in a way, a lot more innovation that they could embrace, but because they didn’t expand, they don’t know. It’s a Catch-22. They don’t have the burning platform to try to control costs because they didn’t expand, and at the same time, [because] their providers are traditionally the lowest reimbursed, especially like for childcare, they’re not going to be incredibly motivated to do things that take a lot of effort and investment, when they are not receiving the benefits of that investment. So that’s partly why expansion vs nonexpansion becomes a pretty critical issue if the administration changes; the Biden administration will have to do things to get those states to meaningfully expand, or it has consequences for a public option, because then it puts a lot more of a disproportionate burden on a public option to solve all those gaps.
AJMC®: Right. We see it already happening where the nation kind of splits population health wise—if you live in, say, the Northeast compared with the South. We’re seeing that now with COVID-19, regarding the states that adopted the mitigation measures early on compared with the states in the South that did not. What do you think the administration could do about that sort of issue? Is it just political?
Patel: I like to think it’s beyond political. The very surface answer is yes, it’s political, red and blue. That’s extremely clear. However, just look at the states: As of the time of this taping, we’ve got about 15 states that are seeing record growth in COVID-19, and they’re mostly the red states—you’ve got the Dakotas, Iowa, Alabama, Tennessee, Georgia, South Carolina. So I’d like to actually say that COVID-19 offers a glimpse into what happens when you don’t have that aspect of the health care system. And my friends who, myself included, come from one of those states, Texas, and my friends in those other states I mentioned, they’ve said that now there’s increasing awareness that a lack of a safety net or lack of an insurance mechanism for people is really costing the state overall. So, in a Biden administration, there’s going to be the part that’s political, but if you get past the politics to some degree, and you can illustrate that the states’ budgets will probably actually in the long run save money, or you’d have to see if there’s legislation to [back up] giving those states extra support. And because if the ACA stuff is gone now, what could we do? You know, what could Democrats do? What could a Republican Senate be willing to do? I’d like to say that it could go beyond the blue and red, but it would have to come with dollars. That costs money. We don’t have any money, but that costs money. And then it would also have to come with probably a lot more technical support. One of the things I have learned is that expansion is not easy, and states that don’t have the infrastructure to support some of this are particularly more likely to say “No, thank you.” States will leave money on the table if it feels like it’s going to be overly burdensome. So, I think that a Biden administration would have to offer both money, through Congress, but also support, which would be through CMS.
AJMC®: When you reference yourself and your friends in health care, how have the conversations with your patients changed from when you started practicing medicine to the past couple of years to now? What are they worried about?
Patel: It’s funny because I’ve kind of done a full circle in my life. When I started, my first clinic out of residency was in a safety net setting, with people who were uninsured or underinsured, and then I spent years going through a more traditional primary care setting, with people with commercial insurance, Medicare, some Medicaid but not as much, and certainly not as many uninsured. Now I am primarily practicing in a federally qualified health center in DC and Maryland, and of the people I see, two-thirds have no insurance and one-third have Medicaid. Here are the things that have not changed: If you are in a lower socioeconomic status, you are always cost sensitive, always. Like the patients 20 years ago who were in Los Angeles, California, in a federally qualified health center—for my patients, cost was everything. [Even to pay] $4 for ibuprofen, it was very common for me to get approached to see if I could get [it for them]—all federally qualified health centers use the 340B pricing program to get drugs and this is where it works, because they would ask me, “Is this something that I can get through the clinic?” and that is exactly the same. Now, I would say, though, that what’s changed especially—put aside that people have lower insurance access, lower socioeconomic status, lower health literacy—I would say even my most high-insured, wealthy, higher-education patients are becoming more aware of cost issues. They may be able to afford everything even out of pocket, but they’re asking up front about costs more.
And then the other conversation that’s interesting to me is that there’s much more awareness, particularly with procedures, about the relationship between quality and volume. It’s interesting to me when I have patients who would say, “Has that doctor done a lot of hip surgeries?” and so you realize that what they’re doing is they’re connecting the dots that volume actually matters in certain things. And then, the other thing I would say is the [evolution of the] internet era. The internet certainly existed when I started out in practice, but with the ability to get information at your fingertips and the frustrations that patients have with how clunky the health care system is, it’s just much more dramatic. Ten years ago, my patients wouldn’t mind being on hold for 20 minutes to figure out how to schedule something, and today there’s just very little tolerance for that. And that actually is across the board—across race, ethnicity, gender; it breaks all barriers. Everybody is squeezed for time; time is the most precious commodity. Health care does a really crappy job of helping people make time efficient: time lost in waiting rooms, time lost on phones, time lost on fax machines. I can’t believe, in clinic the other day, we heard that one of the local CVS locations that we commonly use was not getting our e-prescriptions efficiently, so we now needed to switch to fax. Only in health care would someone say, “The computer’s not working. We need to go back to fax.” So, that’s a long answer to your question, but I think it’s been an interesting journey to see how health care in some ways has changed dramatically and in some ways, it’s still the same.
AJMC®: From the patient side, especially for the population that you serve in the health centers, is there a downside to telehealth when you think about access and health literacy?
Patel: We have had predominantly all our patients doing telephone, not video, and it’s for the reasons I think you’re referencing. These are people who don’t have high-speed Wi-Fi at home. Most of the time, they’re taking the calls from someplace at work, or the number of screaming children in the background I’ve had on my patients’ calls with me is almost 100%. These are the moms, especially—since I see a lot more women than men—taking care of lots of kids and managing jobs. So, the good news is that telephone access for them to be able to do their care has actually helped us with compliance and adherence. I’ve been able to actually have follow-up visits, where I [otherwise] would not have been able to because people couldn’t get time off, and waiting for half a day in our clinic’s waiting rooms just was not feasible pre–COVID-19. Telephones made things a lot easier, but that will only last as long as we have this parity between phone and video and some in-person visits. Once that shuts off after the public health emergency, we’re going to return to business as usual. And [because] we had so much success with telehealth—we’re talking about this right now internally—even if they don’t pay as much for it, we want to keep some elements of telephone care. The trillion-dollar question is, what percentage of visits really should be virtual? And nobody really knows the answer to that.
AJMC®: In terms of what you’ve seen over the past decade or two, what have you seen change in terms of chronic disease and also substance use disorder (SUD), which we know is being affected by the pandemic?
Patel: It’s a great question. More than 10 years ago, I worked in the Senate when one of the first—we called them demos back then—chronic disease demos in diabetes was launched, and it was a big failure. It was a failure because it just wasn’t designed very well. So, I think that we’ve done an amazing job in the past decade of understanding how to design effective chronic disease management programs; we learned a lot over the years. We also realized that there is no such thing as a single chronic disease: You don’t take care of the diabetes without also dealing with their mental health and with their new cancer diagnosis, etc. We’ve done a much better job of [understanding] poly chronic disease, treatment interventions, heart failure, readmissions, helping people figure out their medications after discharge—that’s a lot of work that we’ve done. But then to your second point, we have never done with substance use and behavioral health disorders what I mentioned doing in diabetes and heart failure and asthma, for a lot of bizarre reasons, including the financing of behavioral health being carved out, as well as the fact that we never really integrated people like me, primary care doctors, with mental health providers previously. I think that in a telehealth era, there’s a lot of promise, but we have to overcome some of those structural barriers. For example, you cannot [prescribe] buprenorphine, you cannot get someone off opioids, without face-to-face or video visits. I can’t do telephone medication assistance therapy counseling to get someone off opioids. That’s crazy. Why is that? Because of the structural barriers. So, I think we still have a lot of work to do on the SUD/mental health side. I think it’s possible. I am hopeful that this is, again to your first question, coming out of COVID-19. I think with behavioral health and substance use disorders, it is a tipping point, and I hope that can change.