There is not enough attention focusing on the biggest issues in the healthcare industry.
Margaret Okane, founder and president of the National Quality Assurance Committee, and MD Sachin Jain, president and CEO of Scan Group & Scan Health Plan.
This is a review of Sachin Jain (MD), president and CEO of Scan Group & Scan Health Plan, and Margaret O'Kane, founder and president of the National Quality Assurance Committee. They both spoke with Chief Healthcare Executive® in a recent joint interview to discuss structural issues in healthcare and the need for bold change.
They did not restrain them. They talked about affordability, accessibility and opportunities for change.
Beyond these challenges, Jane points out a clear lack of leadership in the healthcare industry.
“There's a leadership crisis in healthcare in the US,” says Jain.
“There are policy instruments that have been in place over the past 20 years that have known something, and have chosen not to act on it, and have actually used that knowledge to create a sustainable business model, and you have not acted on it. What is the explanation?
“It's designed to increase costs.”
Americans pay a lot for their healthcare, and they say it's a reflection of the system.
“We need to reduce costs. We think we created a system that was fully designed to reduce costs,” says O'Kane.
“The current system has its own momentum and is actually accelerating in terms of increased costs,” she says. “So, what do we need to do differently? I think we need to be a little more comfortable staying on the current course you are in.”
Hospitals could be fined at a higher percentage of patients who are readmitted, but Okane says some hospitals are used to paying those costs comfortably.
She suggests that the federal government should take a more aggressive approach, such as a warning hospital that could double penalties if readmissions were not reduced.
“Drive just along the coast and do some things that will really make it difficult to play the current game,” Okane says. “This administration has shown a willingness to disrupt Apple Cart in a number of ways, which could be something that has a huge reward.”
Both O'Kane and Jain see President Trump's administration and opportunities for substantial change. Jain acknowledged that the administration is “polarized,” and some healthcare leaders are wary of cuts in health funding and changes in vaccine policies.
However, Jain says there is a willingness from the administration to focus on chronic illnesses and promote efforts to gain healthier current opportunities.
“The job of everyone who wants to improve healthcare is to try and adjust what's right for patients with the policy orders that come out of this administration. That's the work for the next few years,” Jain says.
“I think the system actually has more courage than it took a long time to create change,” he adds. “I think we are seeing a new look at a lot of very unusual things that are normalising in our industry right now, and I think there are plenty of opportunities for positive change. The interesting thing about positive change is that it doesn't come out without suffering from the status quo.”
“Value-based fantasy”
They argue that health systems also waste opportunities with value-based care.
“For me, I think the whole idea of fees for the service is crazy,” Okane says.
Okane says her idea of value-based care is “really surrender.”
But she says there is a public perception issue. Americans believe that providers will not get what they need in a prepaid value-based system to cover the costs of their population and stay healthy.
O'Kane considers value-based care as “living on a budget” and receives some degree of risk adjustment.
Over the past decade, value-based care has been undermined by the healthcare system.
“I think value-based care has really turned into value-based delusions and value-based illusions,” he says.
“I think it's really unfortunate that's what actually happened over the last decade, because it was taking concepts that were really rooted in meaningful things. And the whole industry has used some loopholes to really take advantage of the wider system, and thus creating the unsustainability of the very vehicles that were created to allow them to go beyond what's right.
Jain and O'Kane see opportunities to improve value-based care, but they argue that the Centers for Medicare and Medicaid Services need to take a different attitude and that Congressional action is necessary.
“Better preventive service”
Both Jain and O'Kane highlight the need for greater investment in primary care.
“If we can focus on long-term views of healthcare costs and long-term health situations, we can invest in outpatient care rather than inpatient care, invest in primary care through specialized care, and in primary prevention as opposed to managing secondary combinations,” Jain says. “If we can turn ourselves around that, we have a very different health care system.”
Primary care accounted for just 5% of all US healthcare costs in 2022, according to reports from the Milbank Memorial Fund and The Physicians Foundation.
Specialized care physicians earn far more than primary care physicians, so this system provides more incentives for physicians looking to pursue a career in specialized care. And that is not a difficult choice for students with high debt.
“People go to medical school, and that costs a lot of money,” Okane says. “They have to take on the debt, and they have to decide what I want to do? Do I want to do this really low-paid, really difficult job?
Okane refers to diabetes as an example.
“You can really manage diabetes, and if you really manage it, you really prevent it from progressing to kidney failure,” says Okane.
“We need better preventive services, but we also need more proactive management of those who need it,” she says. “And there are a lot of tools for that.”
Jain points to the use of professionals that primary care physicians can better serve their patients.
“There are a lot of specialist visits, such as post-survival visits of Cancer to oncologists that are better performed by primary care physicians with screening guidelines,” Jain says. “But instead, we eat a lot of appointments, expensive appointments with experts that don't need to be implemented. So, again, I think we'll see a different allocation of services if the healthcare group is at a high risk of total cost of care.”
The Manhattan Project for Competition
Jain says there is a need for more competition in the industry as consumers see rising costs.
“I think the Manhattan Project is needed to improve the competitiveness of healthcare,” Jain says.
The health giants have led to more integrated care, but they have had a major impact on pricing.
“As more and more groups consolidate, they do so almost explicitly, with the aim of exercising more pricing power,” Jain says. “That's part of the playbook, and again, the sad part about it is that a lot of these organizations have lost sight of their true purpose, not for-profit organizations, they have begun to act more and more like large corporations than as service-oriented entities,” he said.
O'Kane likened the current healthcare system to having every part of the car on the lawn and ordering people to take abandoned cars for drives. She repeats the Jains' appeal for more leadership.
“I think it's right that Sachin is trying to find people spine, find their originality and courage and really get out there and do things,” she says. “And I don't think anything will change without these elements.”
