QUESTION: Hawaii health insurance premiums are rising at nearly twice the rate of inflation, which is very frustrating. Can you explain what’s causing that and what can be done?
ANSWER: I think the problems we have are numerous and they’re certainly not simple. We have a structure where there’s runaway cost, and even though there’s lot of regulation in health care, there is not really regulation that helps us manage the cost in a more effective way. So we have a system that rewards lots of procedures, lots of high-tech services. It really rewards growing the extent of the system, but it doesn’t reward trying to improve the health of populations, trying to manage care in a more effective way. It doesn’t reward primary care and the basic services that everybody needs.
Q: How can that be changed, or can it be?
A: I think it can be. It is going to be tough, and part of reason it’s going to be tough is that we have population issues that, basically, we need people to take more responsibility for their health and try to improve their health. We have an obesity epidemic, and that leads to a lot of chronic diseases, including diabetes and chronic heart disease, problems (that) are showing up earlier and earlier in life. People don’t necessarily have good diets, they don’t exercise enough, people still smoke, although fortunately that trend is going down. So we do have a lot of population health issues, but the things that I think we can do best are try to rein in the cost by using electronic health records, exchanging information and keeping track of data better. So even though, really, the things that we need to do to improve our health care system are changing the way we deliver care, (we need to be) changing the way we pay for care, and putting our consumers or patients — people — right in the middle of care. But much of what we need to do is to build an effective health information technology system to support that.
Q: Are you talking about the system France has, where a person carries his or her whole medical history on a pocket-sized computer chip?
A: That would be useful, although what I’m really talking about is, the vision is, that every health care provider, physicians primarily but others as well, have good electronic health records that they use in their offices and they use them effectively to identify their patients, to manage the care of their patients. Good electronic health care records have decisions support built into them so that if they have somebody who has a given condition, the electronic health records themselves can help guide the therapies, that they use this electronic data to exchange it with other health care providers as necessary. Say I have a primary care doctor, I also have a specialist and the specialist and my primary care doctor can exchange my information, so that the specialist doesn’t have to run all the same tests again.
Q: Isn’t that existing today in Hawaii?
A: I wish it were. No. It is very rare to see either providers effectively using electronic health records or exchanging that information.
Q: Would that cut down on the cost?
A: Yes it would. For instance, what I said about the exchange of information. So there is a lot of duplication of tests and services and unnecessary prescriptions and all kinds of stuff because my one doctor here doesn’t know what my other doctor has done, and the system has no way to put those things together, as it is now. So maybe your insurer knows all the things that it’s being billed for, but that doesn’t really help in any meaningful way. So it’s not like the test that I had for cholesterol is going to my cardiologist at all. So that would certainly reduce some of the cost.
Q: What else would reduce the cost?
A: Well, that would also help reduce the cost by reducing medical errors, because, right now, if you show up unconscious in the emergency room, they have no idea about your allergies, your health history, your medications, none of that stuff, and so there is much more chance of errors being made. … Let’s say that at least they have your ID, so that if we had a really good competent system, they would put your identification into the system and out would pop your connection to the physician that you go to regularly and at least some of the basic information about your prescription, your lab tests and your basic health history, so that they have a starting point.
Q: Even if it’s not within your system?
A: Yes.
Q: Because people share between systems?
A: Yes. They don’t do that now, not very much. Kaiser, of course, they have invested a lot in electronic health records and exchange and all of that stuff, so that if you’re in their system, then wherever you go, they will have good information about you, and that would be really great, but Kaiser is only a small part of the health care world. In the rest of the care world, we don’t have providers who have electronic health records. We don’t have a system that exchanges information back and forth.
Q: Would this improve when the entire federal health care system is in place?
A: Yes, this is central to some of the things that the (federal) Affordable Care Act is trying to accomplish. So the Affordable Care Act is providing incentive payments for providers to get on board with electronic health records. They’re called meaningful use incentive payments.
Meaningful use is the term of art that they use to talk about having meaningful use in your electronic health records. That is, they usually get some decision support registries from your chronically ill patients so they can keep track of their status better, and they do use them to exchange information among providers, and also with the Department of Health for the things they need for public health purposes. …
They’re also funding information exchange. So right now we have an organization in Hawaii called the Hawaii Health Information Exchange, which is setting up the rules and policies for information exchange between providers, so those things can actually happen. …
The Affordable Care Act is providing some funding to the insurance division, so that they can monitor insurers and premiums and what’s going on there, and I think that will be good, because it will add transparency to the system, which is not currently available.
The Affordable Care Act also is going to help us by funding the establishment of the insurance exchange, and that’s moving forward right now.
