The Going Below The Surface (GBTS) Forum – representing patient groups, providers, payers, employers and life science organizations – announced a series of efforts to drive an informed, sustained and action-oriented dialogue addressing U.S. health spending issues. The Forum’s work is designed to raise awareness of and tackle a variety of health spending challenges, starting with key questions on how much and how best to spend on health care. Activities include an initiative to address low-value or unnecessary care, town halls and this monthly e-newsletter.

If your organization is interested in getting involved, let us know — drop us a line or tweet using #GoingBelowTheSurface.

Digging Deeper

This month we consider whether some seemingly obvious initiatives to improve patient outcomes and lower health care costs actually fulfill their promise through two recent studies: one evaluating the impact of coordinating care and another looking at what happens when free medicines are provided to patients. Their findings prove that we cannot rely on assumptions and instead must ensure we are implementing evidence-driven solutions.

Cost Is Not the Sole Contributor to Medication Adherence

It’s not news that affordability remains a concern for patients. One hypothesis suggests that eliminating out-of-pocket costs for patients could dramatically increase the chance that patients will take prescribed medicines. That premise may be reconsidered in light of a new study from JAMA Internal Medicine that found financial barriers might only play a limited role in medication adherence.

In Ontario, Canada, researchers provided free essential medicines to nearly 800 patients who reported being concerned about medication affordability. After one year, the patients’ adherence rates plateaued at the 38% mark. While that is better than the 26.6% adherence rate in the control group, the results suggest that pricing is not a magic bullet for guaranteeing adherence or outcomes. Ultimately, while providing free medicines resulted in a small increase in medication adherence, a full 62% of patients continued to have difficulty sticking to their medication regimens even when out-of-pocket costs were eliminated.

Why it Matters: Providing free medicine is not a cure-all for patient adherence. The JAMA Internal Medicine study was optimized for success: patients even received their prescriptions by mail, which has also been shown to boost adherence. The findings of this study suggest solutions will need to focus on more than just price; other barriers must be considered. In order to fully address concerns around spending and patient outcomes, stakeholders across the system must continue to understand the role that patient education, patient reminders and social determinants of health play in patient adherence.

Are Accountable Care Organizations Providing More Affordable Care?

Accountable care organizations (ACOs) were created to coordinate care services with the ultimate goal of delivering high-quality care while reducing costs. Preliminary studies on ACOs’ results have shown modest declines in spending for patients and hospitals, but a recent study in the Journal of Clinical Oncology (JCO) found those results may not persist over the long term, at least not in cancer care.

Miranda Lam, a radiation oncologist at Dana-Farber Cancer Institute, and her colleagues compared Medicare claims data from 2011 to 2015 for beneficiaries with a cancer diagnosis at ACO practices with non-ACO practices in the same geographic region. The authors found that the introduction of ACOs had no meaningful effect on spending or utilization for patients diagnosed with 11 different types of cancer.

Why It Matters: The new findings on the inability of ACOs to impact spending for costly diseases illustrate the danger of assuming one cost-saving approach will automatically work across all conditions. Looking hard at possible reasons for a lack of cost savings—the authors of the JCO piece indicate that the difficulty in treating complex diseases, as well as a drive toward value-based care, is impacting ACOs and non-ACOs in similar ways—will be critical in fashioning future care models that can deliver high-quality care for less money.

What We’re Reading

Why is it so hard to reduce low value care and inject more high-value practices into our health care system? Here are some journal articles that examine the question.

  • Shrank WH, Rogstad TL, Parekh, N. Waste in the US Health Care System: Estimated Costs and Potential for Savings, Oct. 7, 2019. JAMA.
    Can we quantify wasteful spending the United States? This study found that waste in the U.S. health care system “ranged from $760 billion to $935 billion, accounting for approximately 25% of total health care spending.” And while it was too difficult to project savings from reducing administrative waste, there’s still the potential to save from $191 billion to $282 billion in other areas.
  • Berwick D. Elusive Waste: The Fermi Paradox in US Health Care. Oct. 7, 2019, JAMA.
    Former Centers for Medicare and Medicaid Administrator Dr. Don Berwick rebukes health care stakeholders for their lack of political willpower to actively address and reduce wasteful spending. He writes: “[R]emoving waste from U.S. health care will require both awakening a sleepy status quo and shifting power to wrest it from the grip of greed.”
  • Figueroa JF, Horneffer KE, Jha AK. Disappointment in the Value-Based Era: Time for a Fresh Approach? Oct. 9, 2019. JAMA
    This study takes a look at why value-based programs have failed to deliver on the improvements in patient care that had been expected. The authors suggest that focusing on high need, high cost patients could be a good place to start, because those patients are particularly vulnerable to the effects of low-quality care. “By prioritizing and incentivizing metrics that reflect the unique needs and preferences of patients,” the authors explain, “it should be possible to better build a high-quality health system that is responsive to all patients.”
  • Goldman D. CBO Estimate on Pelosi Drug Bill Misses its Long-Term Impact on Health. Oct. 16, 2019. USC Schaeffer.
    Economist Dana Goldman writes that we need to consider the kinds of trade-offs that might be necessary if the federal government imposes price controls on medicines, such as continued innovation and long-term health care benefits.’

Dialogues on Health Spending

Conversations about health care spending continued this month during regional town halls, podcasts and journal articles.

  • Talking Health at Town Halls. The Going Below The Surface Forum partners hosted town halls in Columbus, Ohio (Nov. 6) and Salt Lake City, Utah (Nov. 7). Participants discussed challenging topics ranging from spending on end of life care and reducing low-value care to determining patients’ responsibilities for their health and utilizing technology in health care. More town halls are being planned for 2020.
  • Trade-offs Podcast Launches. A new podcast hosted by reporter Dan Gorenstein digs deeper into understanding our complex health care system. Much like Going Below The Surface, his podcast is aimed at having “smarter, more honest health policy conversations.”
  • Considering Health Spending. As part of the “Considering Health Spending” series in Health Affairs, published studies examined the impact of health care spending on households, changes to the Merit-based Incentive Payment System, and North Carolina’s Medicaid transformation.  (Note: The series is funded by the National Pharmaceutical Council and Anthem, Inc.)

Join the conversation by following us on social media using #GoingBelowTheSurface or send us an email at Want to receive this e-newsletter in your inbox? Subscribe via this website.