The Most Important Healthcare Legislation Since the Affordable Care Act
“We all know that employers with 401(k) plans have a fiduciary obligation to look out for their employees’ best interest when it comes to their retirement plans. Now, under the CAA (Consolidated Appropriations Act), employers must bring that same, heightened level of attention and care to their group health plans.”
“If you’re a company owner with a health plan, part of your new fiduciary duty requires you to certify this year that you’ve put into place a process to understand and fully report on the details of your benefits program and prove you are working in the best interest of plan enrollees. To do all that, you’ll need to have a rigorous procurement process in place.”
Translation of the last highlighted statement: The CAA mandates patient-centered care.
These provisions should lead to a massive change in self-insured employer health plans. Care today is anything but patient-centered for patients with cardiovascular and related conditions which represent about a third of costs. Almost everything in American medicine is focused on the next new thing—the next new drug, the next new device. Our system is designed to rescue patients with acute events like heart attack or stroke late in the disease process. Our system is the best in the world for that. It is one of the worst in the developed world at identifying individuals who are headed for heart attack, stroke, and dialysis and keeping them healthy. It is not designed to review and bring together all the research in a proven comprehensive program to protect cells and organs. Self-insured businesses now have an obligation to make certain their health plan enrollees are receiving care designed to address their chronic cardiometabolic conditions effectively. I don’t know of a single one that is doing that.
The legal term is “knew or should have known.” The National Academy of Medicine called for drastic changes in the way our system addresses chronic illness over 20 years ago. This is the organization that makes recommendations on healthcare policy changes at the highest level. They essentially called our healthcare system a dumpster fire: “The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive…Between the health care we have and the care we could have lies not just a gap, but a chasm.” It is not a crack in the sidewalk, it is the Grand Canyon.
There is no better example of this chasm than cardiovascular and related conditions. Over the twenty years since that report we have learned so much about the epigenetics and molecular biology of chronic cardiovascular diseases that we can very precisely block the changes that cause chronic illness and aging. When best practice medical and lifestyle interventions are combined in a protocol administered by a team of nurse practitioners, that is called optimal medical therapy. Compared with the care that most patients receive—usual care—optimal medical therapy (OMT) is in the best interest of plan enrollees.
Despite a mountain of evidence supporting OMT and new guidelines that call for OMT first, before stress tests, heart artery catheterizations, and stents, our healthcare system is still designed around opening blocked arteries in patients with stable heart artery disease. OMT after a heart attack reduces all-cause mortality by 90% and costs by tens of thousands of dollars compared with usual care. OMT in patients with type 2 diabetes and chronic kidney disease is equally impressive. Patients who received OMT had one fourth as many heart attacks, one fifth as many strokes, and one sixth as many many went on to dialysis. They lived eight years longer. Heart attacks and strokes are delayed by eight years. The number of patients admitted to the hospital for congestive heart failure was reduced by 70%—and all at lower cost per patient per year. (It would be even lower now because the medications have become generic and cost much less.) OMT for patients with cardiovascular and related conditions is in the best interest of your health plan enrollees.