Executive order on improving price and quality transparency in healthcare

Today, President Trump did something long overdue to aid users of healthcare and their families. This executive order (EO), still does not provide for more people to become insured, without further marketplace changes, which are not encompassed in this EO. And the EO will not accomplish everything needing to be rectified by our vastly flawed health care system.

Portions of the EO include a number of sections

1. Purpose

My Administration seeks to enhance the ability of patients to choose the healthcare that is best for them. To make fully informed decisions about their healthcare, patients must know the price and quality of a good or service in advance.

2. Policy

It is the policy of the Federal Government to ensure that patients are engaged with their healthcare decisions and have the information requisite for choosing the healthcare they want and need. The Federal Government aims to eliminate unnecessary barriers to price and quality transparency; to increase the availability of meaningful price and quality information for patients; to enhance patients’ control over their own healthcare resources, including through tax-preferred medical accounts; and to protect patients from surprise medical bills.

3. Informing patients about actual prices

regulation, consistent with applicable law, to require hospitals to publicly post standard charge information, including charges and information based on negotiated rates and for common or shoppable items and services, in an easy-to-understand, consumer-friendly, and machine-readable format using consensus-based data standards that will meaningfully inform patients’ decision making and allow patients to compare prices across hospitals.

4. Establishing a healthcare roadmap

Within 180 days of the date of this order, the Secretaries of Health and Human Services, Defense, and Veterans Affairs shall develop a Health Quality Roadmap (Roadmap) that aims to align and improve reporting on data and quality measures across Medicare, Medicaid, the Children’s Health Insurance Program, the Health Insurance Marketplace, the Military Health System, and the Veterans Affairs Health System. The Roadmap shall include a strategy for establishing, adopting, and publishing common quality measurements; aligning inpatient and outpatient measures; and eliminating low-value or counterproductive measures.

I devote special emphasis on this section because the possibilities for good and pitfalls for the unwary are still common, and likely will continue, perhaps in a reduced form, despite this EO.

"You get what you pay for"--hopefully. High cost does not ensure high quality. Nor does low cost imply low quality. Outcome measures as a marker of treatment quality are fraught with trouble. Oncologists' outcomes will always be worse than dermatologists outcomes. Who is to rate the expected outcome of particular specialities? Will a procedure by procedure analysis be useful? For instance hysterectomy for vaginal-rectal prolapse is more complicated with lower success and lower patient satisfaction than hysterectomy for in situ cervical cancer.

Online patient ratings are notoriously unreliable, skewed to both the highly satisfied and to the highly dissatisfied concerning their medical care experiences. The EO does however discuss "shoppable" procedures. This means, procedures (and providers) for whom there are more than one choice. Of course the out-of-network issue is a major element in preventing just such shopping. Until physician/hospital/lab/imaging networks are expanded, the idea of shoppability is but a fond desire, bereft of ability from which to benefit. I do not see that issue directly addressed in the EO.

5. Increasing access to data to make healthcare information more transparent and useful top patients

the Secretary of Health and Human Services, in consultation with the Secretaries of the Treasury, Defense, Labor, and Veterans Affairs, and the Director of the Office of Personnel Management, shall increase access to de-identified claims data from taxpayer-funded healthcare programs and group health plans for researchers, innovators, providers, and entrepreneurs, in a manner that is consistent with applicable law and that ensures patient privacy and security.

Sounds great but this is a golden pipe dream from the experience of this essayist who for four decades has been a practicing physician. One of the reasons, I got out of medicine was the onerous Electronic Health Record (EHR) requirements imposed by Obamacare. I know of no clinically helpful EHR program that is physician-friendly. Admittedly, I have been out of the loop for a few years but my medical colleagues agree that these expensive, usually cumbersome programs are written by geeks for geeks--not for physicians or their patients. Too often, the physician or physician "extender" has their nose stuck in a computer screen, rarely making eye contact with the patient sitting across from them, anxious to have their story register with the physician--not simply as a series of seemingly disconnected data points. Because, that's what these EHR do. They parse all patient-related information into discreet data points, as demanded by the EHR--otherwise the information cannot be entered into the sacred computer.

EHR's do not afford physicians the latitude to make their diagnostic conclusions in ways relevant to patients's problems without traversing numerous computer-necessitated gymnastics. So the quality of intelligence by which we hope diagnoses are achieved are given short shrift. I don't have a solution for the EHR dilemma. Hopefully, someone will have found such.

6. Empowering patients by enhancing control over their healthcare

, the Secretary of the Treasury, to the extent consistent with law, shall issue guidance to expand the ability of patients to select high-deductible health plans that can be used alongside a health savings account, and that cover low-cost preventive care, before the deductible, for medical care that helps maintain health status for individuals with chronic conditions.

This sections leaves me confused. It seems to be advocating for coverage of low cost preventive maintenance, as it were, separate from the high deductible programs already in existence. Perhaps this is a mandate to do what the ACA already does, provide for preventive healthcare, known also a "well-care". Such well-care is a cost-saving idea which, if used more broadly, could be a huge cost-lowering factor. The availability of low cost preventive care might entice those currently reluctant to enter our overpriced healthcare "market" to seek services that should be availed of by all individuals.

7. Addressing surprise medical billing

Within 180 days of the date of this order, the Secretary of Health and Human Services shall submit a report to the President on additional steps my Administration may take to implement the principles on surprise medical billing announced on May 9, 2019.

As a consumer of healthcare, and I have consumed a lot--not by choice--I, too have received these unwelcome surprises. Most come from out of network charges but also some come with the deliberate unbundling of procedure costs which are ordinarily combined.

This is a step forward.

It will help pave the way for M4A. Once the public can be persuaded that governmental regulations, such as promulgated by this EO can be helpful, citizens may not be so reticent to accept further governmental control of healthcare, which Medicare in its still limited form provides.

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Comments

earthling1's picture

is who wrote this EO?
Who really benefits?

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Alligator Ed's picture

@earthling1 It's the content which counts. Do you ask who cooked the hamburger when you go to the burger joint? Who benefits--healthcare consumers--at least the insured ones and those who might be able to afford high deductible insurance.

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travelerxxx's picture

@Alligator Ed

I wouldn't be too hard on our fellow c99'er earthling1. I had to read quite a way into your post, and even the comments, before I was somewhat convinced this wasn't snark. In fact, I followed your link to be certain it wasn't the Onion or some satire site.

I simply do not expect the current administration to do anything that doesn't primarily benefit huge multinational corporations, with any advantage to we plebs simply luck. By the way, I had aquired this attitude long before the present denizens of the White House moved in.

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another level of confusion and bureaucratic nonsense, anything that highlights the insanity of this "health care system" is worth it.

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Alligator Ed's picture

@Snode With M4A such an EO would be unnecessary because government regulators control prices allowable. If a procedure not currently covered by Medicare is recommended, the patient is officially notified in advance (providing it's non-emergency) and allowed to obtain it at their own cost--if they can. Secondary insurance is a great help in any event. If one is on Medicare, one should obtain the so-called Medical-gap plan available. Premiums are surprisingly low.

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@Alligator Ed My wife has worked in a smallish rural hospital for the last 25 years. All this legislation looks great on paper, but much of it ends up being a collection of unintended consequences. The hospital she works in (non clinical position) didn't pay well, but the insurance was pretty good. Obamacare and the institution of the high deductible and copay system ended up being a pretty big pay cut. The cost of the insurance plus another $7200 and then they take over. We avoid as much doctoring as we can.

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services than I ever imagined I would need, almost always on an emergency basis. So, while I lack your medical knowledge, I know a bit about being a patient.

Disclosure can be important, yes. On the other hand, sometimes it can be almost irrelevant. I've never shared much on any board about my off board life, especially its less fun bits, but this seems important enough. I'm very uncomfortable doing it, so please bear with me.

My health situation is complex. It does not consist of just one serious problem, but several, some of which could kill me very suddenly or do such damage that I would be sorry it didn't kill me instead. One of them is, and I quote, "very, very, very, very, VERY rare."

The meds necessary for each of the conditions can exacerbate one or more of the others. I end up going to the hospital via ambulance, siren wailing and all, more than many of you ever will, even if you live to be 115. At least I hope that is so, for your sakes.

Under those circumstances, you don't google a doctor's credentials or compare what hospitals charge for an overnight or anything else. Moreover, in those situations, which end up being incredibly costly, I don't feel confident going to the most cost effective hospital. Rather, I go to the hospital that is both closest to my home and most familiar with my crazy, complex history, to the hospital where a resident can, if necessary, make a 2 am phone call to the doctor who is most familiar with whatever condition is causing the immediate problem. And, yes, to the hospital where many of the professionals have gotten to like me. It also happens to be, thank goodness, a very well-rated hospital.

For me (and others in comparable health straits) disclosure is irrelevant. What I need is damn good health insurance, which I am very grateful to have. Still, those premiums, deductibles and co-pays add up.

Before Obamacare, most of the families that medical costs bankrupted (literally) were those in which both spouses had health insurance. When I posted that on another board a few years ago, someone replied that the same was true after Obamacare as well. However, I did not look that up and therefore cannot say whether it is accurate or not.

I recommend that, if you possibly can, look into doing whatever you can to protect your assets, just in case something catastrophic hits your family. State homestead laws, state bankruptcy laws and estate planning laws are all relevant.

Also, have a medical proxy and, if indicated a DNR (Do Not Recusitate). Put it somewhere an EMT cannot miss it. Choose your medical proxy and alternate carefully. I would not recommend choosing your son or daughter if you have any reasonable alternative Make sure the paperwork states that, whether or not you are conscious, your proxy can get all the information that you could get about yourself, if you requested it. Discuss things like amputation(s), tube feeding and the like with your medical proxy. Also with your doc, if you need to.

It's a lot and not pleasant, but do it while you are able to think clearly and are not in a panic or out cold.

And now, if you'll forgive me, please forget who wrote this post. Please don't reply to it, either. One of the things I've enjoyed about posting has been that, for all anyone knew before this post, I am the healthiest, physically strongest poster in the US. I don't want that to change.

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Alligator Ed's picture

@HenryAWallace You give excellent advice

Also, have a medical proxy and, if indicated a DNR (Do Not Recusitate). Put it somewhere an EMT cannot miss it. Choose your medical proxy and alternate carefully. I would not recommend choosing your son or daughter if you have any reasonable alternative Make sure the paperwork states that, whether or not you are conscious, your proxy can get all the information that you could get about yourself, if you requested it. Discuss things like amputation(s), tube feeding and the like with your medical proxy. Also with your doc, if you need to.

I will match anyone on this board for the different number of medicines required to keep yours truly going. Fortunately all are available generically so are quite affordable, even though providing several mouthfuls per day.

Patients: Be nice to your healthcare providers but if they aren't helpful to you, get different ones. A good bedside manner is an indicator of concern. Concern is a keystone of competence but not the only one. Anecdotal stories are nice, especially when coming from sources you trust. Governmental health tracking is quite crude, especially considering extensive NSA-like surveillance activities to which we are all prey.

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Also, have a medical proxy and, if indicated a DNR (Do Not Recusitate). Put it somewhere an EMT cannot miss it.

Does having it tattooed on your Chest count?
@Alligator Ed

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Ya got to be a Spirit, cain't be no Ghost. . .

Explain Bldg #7. . .

Alligator Ed's picture

@Tall Bald and Ugly unless you are very hairy--in emergencies, I doubt anyone would shave your chest. Of course you could tattoo your desires on your forehead.

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is denial. Slightly off topic, but the lab work involved in determining which variety one has is generally not covered by insurance. The doc's don't push testing that isn't covered. If not treated rapidly, it can effect your joints and immune system for life.

Sheesh

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May we be united and strong -- laurel

Alligator Ed's picture

@QMS Lyme is a spirochete disorder of which the most famous is syphilis. For well over 100 years, medical professionals have become aware of the late, latent, and tertiary forms of syphilis. But Lyme. Oh my, no they say. Why? Because admitting that chronic forms of Lyme exist will require insurers to pay for the hundreds of thousands of Lymers whose medical condition can flare up at any time and cost Inscos money.

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When they sent my kid down to the big hospital to operate before his appendix burst the surgeon while he was reading me the small print to cover his butt and asking what had been done and what had been given at the small hospital tried to pull up the records, all of a sudden there it all was, X-rays, health background, medications given. Big smile from that doc.

The older you are the harder it is to use new software. Teachers hate it too. Oh well.

Transparency in pricing too. I can look at one of the best hospitals in the world, online, and get prices for almost everything. Not for hospitals in the US. Good for Trump.

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Alligator Ed's picture

@ban nock Most young patients have relatively simple past histories, which are usually quite easily handled by most EHRs. But when you have to coordinate the various diseases, multiple tests, disparate physicians and healthcare facilities, most EHR programs will be lacking. I know from my adventures both as a physician and a patient.

By the way, as for reading the fine print to you about possible procedural risks with any test/treatment, a doctor would have to be nuts not to do so. In case you may not know, suing physicians can be like winning the lottery. Plaintiffs lose more often than not but those who win (and their attorneys) hit the lottery. Being sued for malpractice is no fun--I'll leave it at that.

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I would have to agree that the paperwork required is a nightmare. When D.O.'s mother would have to go to the doctor after her primary care doctor was removed from the Medicare Advantage list, she refused to go back to the ones that did not speak directly to her but were busy filling out the forms required of them.

The doctor we have been using takes only Medicare and he hated filling out the forms and not being able to talk to the patient. When I have to go to visit, it is always pleasant and know that he is listening to all the concerns and questions. Hope something good will come from this.

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12 users have voted.

Life is what you make it, so make it something worthwhile.

This ain't no dress rehearsal!

Alligator Ed's picture

@jakkalbessie

The doctor we have been using takes only Medicare and he hated filling out the forms and not being able to talk to the patient.

I couldn't do both--interview a patient and fill in EHR blanks. I got into medicine to help people, not fill in computer statements.

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Unabashed Liberal's picture

if carried out competently, some of these new 'rules' might help folks in the private insurance market.

Of course, the primary reason for the replacement of our Social Security numbers with a neutral Medicare ID number was so that our health care/medical services could be tracked and compiled, and be in compliance with Federal privacy laws.

This proposed 'rule' bothers me, a bit,

The Roadmap shall include a strategy for establishing, adopting, and publishing common quality measurements; aligning inpatient and outpatient measures; and eliminating low-value or counterproductive measures.

How do we know that they're trying to truly eliminate 'bad practices, or unnecessary medical procedures--or, is the true purpose to determine which procedures are most common, and try to find ways to cut back on 'necessary' medical procedures--just to save a buck.

I've heard several so-called health care experts complaining that too many folks are wusses--don't 'need' all those joint replacements. Folks need to learn to live with chronic pain. IOW, just suck it up!

Yeah, not sure that I trust the way that last sentence is worded.

Mollie

“Dogs have given us their absolute all. We are the center of their universe. We are the focus of their love and faith and trust. They serve us in return for scraps. It is without a doubt the best deal man has ever made.
~~Roger Caras

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Everyone thinks they have the best dog, and none of them are wrong.

Alligator Ed's picture

@Unabashed Liberal

How do we know that they're trying to truly eliminate 'bad practices, or unnecessary medical procedures--or, is the true purpose to determine which procedures are most common, and try to find ways to cut back on 'necessary' medical procedures--just to save a buck.

What procedures are unnecessary? So far, except for large practices which want to steer patients away from cheaper and equally (or more) effective procedures to more expensive options is relatively uncommon--I don't say such shifting of treatment plans is rare but in my experience, far from the majority of providers. Ombudsmen are very helpful if one is available to help plead your case, if necessary.

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The Aspie Corner's picture

It will help pave the way for M4A. Once the public can be persuaded that governmental regulations, such as promulgated by this EO can be helpful, citizens may not be so reticent to accept further governmental control of healthcare, which Medicare in its still limited form provides.

Why? Because Dipshit hates "Socialism". So do the rest of the pigs. Pure capitalist fluff.

Edit: And "Gubmint Control" of healthcare? You should know better.

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Modern education is little more than toeing the line for the capitalist pigs.

Guerrilla Liberalism won't liberate the US or the world from the iron fist of capital.

Alligator Ed's picture

@The Aspie Corner Maybe by that time the Demonrats or vibrant third party will grab the reins of gubmint (so quaint) and bring M4A to us plebeians.

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1) I love the transparency with pricing. When I go to a dentist he/she gives me a written estimate for all work to be performed. I can pick and choose. I want the same thing when I go to a doctor/ER/hospital. No exceptions. For me it's lab work that is only sometimes covered by my silver plan insurance. I have many medical problems too. I am informed and am confident in my decision-making for my care. I am glad T is following up on this.

2) Sounds like evil regulation with accompanying growth of government all you stupid Republicans.

This is welcome news!

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4 users have voted.

Are you sure that you didn't read that off an old EO?

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