The COVID-19 pandemic highlighted many of the barriers that make medical care less patient-centered, more expensive, and more difficult to access. Michigan policymakers should learn from this and remove these barriers permanently.
In all states, Republican and Democratic governors responded to the pandemic by waiving barriers that confront both patients and professionals. But that flexibility is long overdue. Policymakers must step back and ensure our health system is ready for the next pandemic.
Making the right changes now would have the added benefit of saving a significant amount of money for patients and small businesses struggling to afford health care and coverage. The health — both physical and economic — of the Great Lakes State depends on taking meaningful action now.
What follows are nine ideas policymakers should pursue
1. Best practice telehealth expansion
The pandemic demonstrated the many benefits of telehealth. While virtual visits can’t and shouldn’t replace all in-person medical appointments, they can save patients’ time and help them avoid germ-filled waiting rooms. Providers benefit, too; they cut down on the risk of exposure and they can see more patients from an office or home. To experience the full potential of telehealth, Michigan should follow these best practices.
Allow all kinds of telehealth method (i.e., live video, remote monitoring, or recorded messages) on whatever device is best for the patient and provider. Michigan law should clearly allow for a form of telehealth called remote patient monitoring. This can help patients remain in their homes instead of being stuck in hospitals for long periods.
Allow across-state-line telehealth with a simple registration regime for those in good standing. This would help with the continuation of care and increase access in rural communities. This has been found to be very safe for patients.
Allow nurse practitioners to use telehealth on their own, without the need to get a collaborative agreement with a doctor.
Don’t pass insurance coverage parity mandates that require insurers to pay for all services. Research has shown mixed outcomes for certain services over telehealth. A mandate also inhibits innovation in care delivery.
Don’t pass a payment parity mandate that requires all telehealth visits to cost as much as in-person visits. Mandates hurt vulnerable patients and small businesses.
2. Allow providers to use their full education and training by liberalizing scope-of- practice restrictions
Access to medical providers is acute in many communities, yet many states, including Michigan, don’t allow providers who have been trained in certain procedures or services to offer them to patients. Previous estimates have found that Michigan needs at least 500 more primary care providers to serve the nearly three million residents of Michigan who live in an area with a shortage of primary care providers.
Liberalizing scope-of-practice laws would allow nurse practitioners, or NPs, to see patients independently for all services they have been trained to offer. Approximately half the states don’t allow independent practice for NPs. In them, a patient is often charged the doctor’s rate to see an NP. A lack of independent practice nurse practitioners drives up the cost of care. State should at least allow them to practice independently in areas with a shortage of primary care providers.
Pharmacists can do more, too, if only state law would allow them to do so. Patients sometimes end up in emergency rooms for things that could be diagnosed and treated by a pharmacist. Idaho and Montana are leaders in allowing more pharmacists to diagnose conditions, administer vaccines, and independently prescribe certain drugs.
States should sunset any scope-of-practice limitation that is not backed up by robust research that reveals concerns about quality of care. They should also expand the medical workforce by liberalizing rules across the care spectrum for nurse practitioners, physician assistants, pharmacists, technicians and aides. During the pandemic, state waivers for more flexibility were key to meeting health needs. The alternative in many communities is for patients to receive no care or to wait months for an appointment for needed care.
Another way to address the physician shortage in Michigan is to reform rules governing how international medical graduates relocate. International medical graduates have to go through another residency when they come to the United States. Rather than require another residency, the state should create a streamlined licensing pathway under which a provider group or hospital can vet the credentials of these graduates. Once the graduates have passed any required state exams and paid a fee, they would receive a full license in the state. Tennessee is leading the way on this kind of reform.
3. Repeal or scale back the government permission slip process for health care facilities and equipment
Certificate-of-need, or CON laws and regulations, require health care businesses to get a government permission slip before they make major purchases such as building a new facility, adding beds to a hospital or making a renovation. These laws artificially restrict the variety and number of care settings and equipment that health care workers can use. Federal officials in both Democratic and Republican administrations have urged states to repeal or reduce their CON laws, which reduce competition, raise prices and lower the quality of care for patients. During COVID-19, states that reformed their CON laws saved lives. They saw a “combined effect of 33 lives saved per 100,000 people,” according to a study in the Journal of Risk and Financial Management. “COVID-19 mortality additionally reduced by 20 lives per 100,000 in states who reformed their CON laws while experiencing demand surges for beds and services.”
South Carolina just repealed most of its CON laws, and Michigan should follow suit.
4.Allow patients to be seen by their chosen provider regardless of the provider or patient happens to be or come from
Pilots can take off from one state, or cross a state line, and we don’t assume they have lost their skills or prevent them from taking off again. Yet our licensing system for medical professionals assumes that pandemics and skills stop at a state border.
Michigan should allow providers who are in good standing in their primary state of practice to register with any relevant board or commission here. In an increasingly mobile nation, preventing care that is given across state lines hurts the health of patients, decreases their access to care, and hampers provider relationships.
5.Reserve Medicaid resources for the truly needy
Medicaid is the largest line item in most state budgets, crowding out other public priorities. In 2020, more than 25% of Medicaid spending went to people who do not qualify. Most states do a poor job of verifying income, residence, incarceration status, or even if enrollees are still living. Since Michigan relies on managed care insurers to deliver much of the Medicaid program, every ineligible enrollee means taxpayers are increasing the profits of insurers at the expense of K-12 education, roads and public safety. Sadly, early efforts by Gov. Gretchen Whitmer to delay verification efforts should give advocates reason for concern.
6.Get patients full price transparency
Whether the concern is treating COVID-19-related symptoms or other conditions, patients sometimes put off care due because they don’t know how much they will have to pay. In Michigan, 57% of adults have problems with the cost of care, according to the Healthcare Value Hub. Three in four adults, or 78%, are worried about affording care in the future. Michigan should build on recent federal regulations on price transparency to ensure a competitive market that will benefit providers and patients alike. Price transparency should be:
Dependable: Prices must be real and reflect what will be paid.
Individualized: Prices must relate to the individual, i.e., helping both those with insurance and those without.
Comparable: Prices must be available for all care settings.
Accessible: Prices must be available early in the process, offered in multiple formats, or at different times to allow education and time to choose.
Actionable: Shared savings should be paid to patients when they save money by making smart treatment choices.
Finally, patients should be able to use lower-cost care out of network and receive credit toward their deductible because they saved everyone money. They should get referred back in-network as needed without penalty.
These reforms finally help align incentives to deliver high-quality care for less.
7. Offer new coverage options, such as Farm Bureau-style plans
Due to ever-increasing costs, fewer businesses are offering health insurance to their employees, and many are dropping coverage in the individual market. During COVID-19, this added an extra burden for millions of Americans. Several states — including Indiana, Iowa, Kansas, South Dakota, Tennessee, and Texas — offer a different approach. These states allow their statewide Farm Bureaus to offer health coverage options that are exempt from state insurance regulations. These plans are 30% to 50% less expensive, while coverage remains robust, featuring statewide networks, free or low-cost preventive care, and options for many additional benefits. Enrollees can renew their policy, even if they get sick or switch jobs. States should allow well-established and trusted industry groups to offer residents these new options.
8.Update state employee health coverage
Michigan spends significant resources on health coverage for active and retired public employees. Most states are missing opportunities to improve the care provided to employees by making changes that would save significant funds for taxpayers and help the state budget. Put another way, Michigan is overpaying by millions of dollars every year for low-quality care. Worse, the care harms the health of its employees and holds the health system back from reorganizing to deliver the best care possible during a pandemic.
Paying employees shared savings when they receive care from less expensive providers will remove overly expensive and lower-quality care options. So will using reference-based pricing for common procedures. States that have pursued one or both of these reforms have saved millions with happy employees who get financially rewards for choosing the right care at the right locations.
9. Protect the doctor-patient relationship
Direct primary care, an arrangement where a patient pays a provider a set monthly fee, was largely unaffected during the pandemic as the rest of the health care system shut down or struggled to adjust. Michigan should ensure that people who use a medical retainer arrangement, another name for direct primary care, can benefit from providers being able to refer them (if they have insurance) to an in-network provider as needed. Insurers often reject these referrals and force the patient to make duplicate appointments. A good response to COVID-19 to ensure patients get the preventative and proactive care they need is to strengthen their ties to their providers.
Reform is needed now
Many people in Michigan have spent years talking about the need to reform our health care system. We should use this moment to codify the flexibilities that result in more patient-centered care.
Not pursuing change comes at a cost. Returning to pre-pandemic practices will reduce access to care, drive up costs, and lower the quality of care patients receive.
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