The health crystal ball on the open table

One doesn’t get many crystal balls in any field, much less health care. But one was put on public display March 5.  It’s worth looking over and addressing on its own terms. Notwithstanding modern hyper-partisanship and super-hyper public skepticism – and an election year – some or all of its predictions could happen. And fortune favors the prepared.

Together with recent budget testimony,[1] Secretary of Health & Human Services Alex Azar debuted his new role to the Federation of American Hospitals.[2],[3]  In particular:

·       Health care value and cost remain the biggest rocks. He is wholly unimpressed that his department’s budget tripled since his last turn there.  “The current trajectories in health spending are both unsustainable and unmatched by increases in quality,” he said. “Since I first arrived at HHS in 2001 our budget has expanded from just under $400 billion to $1.2 trillion today. You might like the idea of coming back to run a hospital system that’s three times as big as it was when you first started, but I assure you, that is not how we feel about the federal government…. It would be one thing if this were accompanied by increasing quality — spending 20 percent of GDP on healthcare to boost our life expectancy to 100 sounds like a pretty good deal!  But it’s not the deal we’re getting right now. As all of you know, part of the problem happens to be the equation that we’ve used for healthcare in this country for decades now: paying for procedures and sickness.”

·       States, step up. Earlier 2017, the administration published proposed rules authorizing association health plans[4] and lengthening short-term limited duration (STLD) plans from 3 to 12 months and authorizing renewals.[5] Both models permit marketing plans that may exclude certain Affordable Care Act requirements[6] such as those that prohibit excluding for preexisting conditions, or other provisions common to health plans such as covering prescription drugs. Presuming the Administration finalizes some version of these proposals and Congress does not override them, states legislatures and insurance commissioners retain wide authority governing what may be marketed as health coverage.  How they use it will vary widely, as will the experience of each state’s residents in our federal system.

·       Health care price and quality transparency are major goals. Sec. Azar illustrated this persistent issue with a story:

A few years ago, my doctor back in Indiana wanted me to do a routine echocardio stress test. I figured this could occur within the scope of his practice, which was connected to a major medical center.

Instead, I was sent a few floors down, where I was told to start handing over all sorts of information to a receptionist. Soon enough, I have a plastic wristband slapped on me, and, to my surprise, what I thought would be a simple test in the room next door had resulted in my being admitted to the hospital.

Now, I had a high-deductible plan, so I would be paying for this test out of pocket. As someone who works in healthcare, I knew that the sticker price on the test had just jumped dramatically by my receiving it within a hospital—something that might never occur to most healthcare consumers. So I asked how much the test was going to cost, and was told that information wasn’t available. Fortunately, I didn’t just fall off the turnip truck, so I persisted, and, eventually the manager of the clinic appeared and gave me the answer. The list price was $5,500. I knew that wasn’t the right answer either. The key piece of information was what my insurer would pay as a negotiated rate, or what I’d pay with cash.

That information didn’t come easily, but eventually, I was told it would be $3,500.

I happened to know of a website where you could search typical prices for such procedures, so I looked up what it would have been if I’d received it outside of the hospital, in a doctor’s office. The answer was $550.

Now, there I was, the former deputy secretary of Health and Human Services, and that is the kind of effort it took to find out how much I would owe for a procedure. What if I had been a grandmother? Or a 20-something with a high-deductible plan?

·       Information technology solutions will help drive quality improvement and price transparency objectives. Another Azar tale:

In recent years, we’ve seen substantial advances in terms of adoption of electronic health records by providers, but all too often, this simply meant putting in electric form what had been on paper, at great expense and burden to the provider.  Useful, but hardly realizing the promise of health IT. And this shift almost entirely left the patient out of the picture. It’s not just that the benefits of health IT aren’t always apparent to patients—it’s that unless we put this technology in the hands of patients themselves, the real benefits will never arrive.

Empowering consumers and individuals has been key to the advances of the information age. Think about how we now often make restaurant reservations, through apps like Open Table.[7] From the restaurant’s perspective, there was nothing wrong with a ledger of reservations or, maybe, a business-focused program for tracking tables. But as a consumer, you had to call from restaurant to restaurant to understand when and where there were tables available. Now, if I pull out my smartphone to make a reservation for dinner on a Saturday night, I have all that information at my fingertips. I’m not depending on the person who answers the phone to get it right. I’m the one in control of the whole process: I can see the available choices, I make an informed decision, and I’ve got the record in my hands.

We already have the technological means to offer this power to patients, but it hasn’t yet happened. The key to this administration’s approach will not be micromanaging the standards and processes used.

We are much more interested in setting out simple goals: Patients ought to have control of their records in a useful format, period. When they arrive at a new provider, they should have a way of bringing their records, period. That’s interoperability. The what, not the how.

Too often, doctors and hospitals have been resistant to giving up control of records, and make patients jump through hoops to get something as basic as an image of a CT scan. The healthcare consumer, not the provider, ought to be in charge of this information.

But this is gridlocked Washington, you say. Congress failed to repeal the Affordable Care Act except the individual mandate, you say. It’s an election year and nothing further substantial will be done on health care, you say.

I say this summer will be hot with this stuff.

Secretary Azar has wide authority to use experiments and evidence to drive payment policy and quality reporting. He also has the responsibility to publish payment rules for hospitals, ambulatory surgery centers, post-acute care, physicians and other health care providers, and other Part B providers. Those proposals will be on the street by July. Public comments will be due by Labor Day. Rules on association health plans and STLD plans may be finalized by then, in time to shape November open enrollment for 2019 ACA exchange plans. An election-eve Congress may struggle to respond to an agency that has flooded the zone – if it wants to.

Clearly for the first time this new Administration, there is an HHS Secretary with a vision beyond “repeal and replace” and the wherewithal to do something about its $1.2 trillion upward spending trajectory – and yours.

The question is, are you ready? Are you a spectator or a participant?


Frank Talk is a product of Cardinal Waypoint LLC, a new consultancy for health policy advocacy and leadership. You can have Cardinal Waypoint at work for you. Contact Cardinal Waypoint here.



[1] Azar A, for the U.S. Department of Health & Human Services. Testimony on the president’s fiscal year 2019 budget before Committee on Finance, Washington, DC, Feb. 15, 2018, revised Feb. 22, 2018., retrieved 3/6/2018.

[2] Azar A, for the U.S. Department of Health & Human Services. Remarks on value-based transformation to the Federation of American Hospitals. Washington, DC, March 5, 2018., retrieved 3/6/2018.

[3] Mostashari F. Twitter thread from @Farzad_MD, March 5, 2018, 8:50 pm ET., retrieved 3/6/2018.  Mostashari is CEO of Aledade and former coordinator for health information technology at the U.S. Department of Health and Human Services.

[4] Department of Labor, Employee Benefits Security Administration. Definition of “employer” under section 3(5) of ERISA – Association Health Plans. 83 Fed. Reg. 614, Jan. 5, 2018., retrieved 3/6/2018. Its comment period concluded Mar. 6. Interestingly, no public comments had been posted to date, a departure from past practice.

[5] Department of the Treasury, Internal Revenue Service; Department of Labor, Employee Benefits Security Administration; and Department of Health and Human Services. Short-term, limited-duration insurance. 83 Fed. Reg. 7437, Feb. 21, 2018., retrieved 3/6/2018. Its comment period concludes Apr. 23, 2018.

[6] Center for Consumer Information & Insurance Oversight. Information on essential health benefits (EHB) benchmark plans. U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Undated,, retrieved 3/6/2018.

[7] The reference does not appear in Azar’s remarks. But without Open Table official Washington would starve.

Frank PurcellComment