Editor's note: This is part of an ongoing series of Q&As with our grantees, "5 Questions With...," where we learn how they are working to maximize opportunity — along with a little something fun.
As President and CEO of Pacific Business Group on Health, Elizabeth Mitchell is laser-focused on improving health care access, quality, and affordability for all — from the businesses that purchase employee insurance plans to the consumers who rely on those plans. It’s no small task, as Mitchell regularly finds herself pivoting from policymakers to health care providers in her work to shake up the status quo.
In the midst of a shelter-in-place from her home in San Francisco, Mitchell spoke to Arnold Ventures in March about the work her group is doing, how her clients are reacting to the coronavirus crisis, and which apps have been most valuable to her in recent weeks.
Employers cover about 160 million people, the largest share of health coverage in the United States, but only a few of the nation’s biggest employers actively negotiate with insurance companies. Why do you think there is a hesitancy among companies to get involved in negotiating health care costs?
I think it’s important for everyone to remember that, for these large companies, health care is not their day job.
They build airplanes, they sell groceries, they have other core businesses, and they are being asked to essentially restructure a system that is extremely complex and, quite frankly, quite resistant to being restructured. And it’s a really heavy lift. It is technically complex, and it is a big ask to ask a customer to change an industry; I can’t think of any other industry that expects that other than health care.
I completely agree that employers have a major role in changing health care, but they also have not been, frankly, all that well supported in doing it by the people they have trusted to do that on their behalf. A lot of the intermediaries that employers have relied on haven’t been particularly effective. That is one of the reasons they are increasingly turning to us and turning to some of their own teams to really innovate and do things they haven’t done before.
We have a 30-year history of helping employers to actively intervene in the market. It’s really different from most employer groups. We have a technical staff of deep expertise in quality measurement and team and model design and contracting, so we are able to support them in a lot of what they are hoping to do. And they turn to us for that. They also really want to learn with and from their peers, so we facilitate that as well. Folks who once might not have been prepared to do some of the more bold and innovative changes, they are increasingly ready to try things and really intervene more in the system than they had in the past.
There’s been some movement in Congress to let consumers off the hook for surprise medical bills. What do you think the chances are of Congress acting on this, and what is the best way for it to be addressed?
I testified on behalf of our members in the Senate last summer on the Lower Health Care Costs Act because it is of such concern to our members. They specifically asked to address air ambulances as an example, because their employees are getting stuck with these outrageous bills and, of course, they pay a large portion of them, so we have been very active in that debate. I heard today that surprise billing may actually survive the current environment, whereas some of the other health care changes are probably going to be delayed for quite some time.
With what’s happening right now with coronavirus, the risks of surprise billing may even increase, so there does still seem to be some momentum around that. What’s amazing to me is the total unanimity among the employer groups, among patient groups, and frankly across both parties; it’s not a partisan issue — everyone agrees something needs to be done. I just think it would be a shame if Congress couldn’t do that.
We were on record in my testimony saying that we thought the best approach to setting payments was actually tying them to some percentage of Medicare rates, like 125 percent, because the data show that that does essentially cover costs. That was not adopted for a lot of reasons, so our second choice was really a benchmark rate — creating a benchmark based on median rate, so being more directive about what the prices could and should be. But again, that was secondary, because that could frankly lock in prices that are already high.
But we thought it was preferable to arbitration, which we do not support. I think that is just an extension of the status quo. You take secret negotiations between suppliers and health plans and you create another form of secret negotiations between providers and health plans. We think it is administratively burdensome and expensive and is unlikely to have the impact that we’re hoping for. As I understand it, they are moving more toward arbitration because that’s what a lot of the lobbying effort is going to from private equity groups and others. But everything has changed in the last week, so it’s very, very difficult to predict.
Through your member organizations, PBGH tests health care methods and scales the most successful approaches for use across the country. What project are you currently most excited about?
We are running a couple of regional pilots with work from Arnold Ventures to change payment for needed care. As an example, we have one pilot happening right now in San Diego with Qualcomm, implementing a maternity bundle to provide optimal maternity care that we designed with Scripps Health systems. And it really shows the power of that direct collaboration. Scripps is really excited to work directly with an employer, and an employer feels really good about the partnership with this provider. Because we had the payment model designed, we are able to contribute something, and we managed to enlist UnitedHealthcare to implement it initially. So it’s about making things happen across the stakeholders, and we believe this is totally scalable and we can improve maternity care.
Employers and employees want the same thing: They want the highest quality, most affordable care that keeps their employees healthy. So this is a real glimpse of what’s possible when you get people working together like that — them learning from each other and learning how to improve care and improve employee outcomes; it’s a great space to be working in. And Arnold Ventures is helping us test these things.
And another one is we’re bringing employers together in the Bay Area to test new payment models for advanced primary care. So because we’re working with some of the practices through our QI program, what they’ve all agreed needs to change is payment — that would enable them to treat their patients differently, to have new and innovative models of care, and payment is the biggest barrier. So by bringing the large employers to the table, maybe we can remove some of those barriers and pay for care that is best for patients. So that’s another AV-funded initiative because no one is really convening the purchasers. There are lots of folks working on QI, but when the biggest barrier is payment, you’ve got bring the people who pay the bills to the table.
What is the biggest health care issue businesses are facing with their employees as the coronavirus spreads?
I don’t even know where to start. There are so many questions. What are the policies? It’s not entirely clear coming out of Washington right now what should be covered and what shouldn’t. Initially, they were asked if they were going to cover the costs of tests, and they had to get guidance from the IRS to cover those costs for employees enrolled in high-deductible health plans, which hadn’t initially been issued. It has since come out. Just keeping up with the pace is challenging.
We heard from them, they are trying to learn from each other, we are facilitating conversations every week right now about what’s working in some regions, so they are sharing lessons, but it’s a lot. I think there is a question, it’s obviously not a priority right now, but what will this do to health care costs next year? I think it’s a real question they are starting to think about, and recent analyses — like the one just out from Covered California — are showing potentially crippling costs associated with the pandemic, which is of great concern. Obviously, the health systems need to be meeting the needs right now, that’s absolutely the priority, but what will this look like next year?
The other thing, which our members have really been prioritizing all along, is what to do about mental health needs. It is a top priority for almost all of my members, and I think it’s just getting elevated even more now. Frankly, there’s just a real limit in terms of access to the care that is needed — in the best of times, let alone right now.
They want reliable information. They are certainly tracking what’s happening in Washington and the implications of that, but how do they just take care of their employees in this very trying time? We are able to give them current policy information, so we do that.
If you had to delete all but three apps from your smartphone, which ones would you keep?
Zoom. [long pause] That changed literally in the last 48 hours. I had one to book all my gym classes, but I can’t go to them anymore — that’s off the table. Sadly, I’ve been using the Amazon app to have things delivered quite a lot, so food delivery. And Calm, a meditation app.