Chapter 17: A Major Challenge: Serving the Uninsured as Health Care Changes
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Description
In this segment, Dr. Foxhall talks about the challenge of expanding access to care, his role as a governor-appointed member of the Texas State Health Services Advisory Council (2009 – present), and the challenge of transitioning from a fee for service system to a value-based care system.
He notes that Texas ranks number one in numbers of uninsured individuals, but there are early signals that the Affordable Care Act is reducing those numbers, though the issue is complicated by the decision Texas made not to participate in the Act.
Dr. Foxhall describes services provided by the Texas State Health Services Advisory Council and gives examples.
He defines value-based care, founded on careful documentation of care provided and outcomes. He explains the related concept of “the triple aim”: to improve quality of care, to reduce cost, to increase levels of patient satisfaction, noting that some policy makers include a fourth aim, insuring equal access to care. He explains why the status quo cannot continue.
Identifier
FoxhallLE_04_20140409_C17
Publication Date
4-9-2014
City
Houston, Texas
Interview Session
Topics Covered
The University of Texas MD Anderson Cancer Center - Institutional Change; Overview; Definitions, Explanations, Translations; Growth and/or Change; Controversy; Institutional Mission and Values; Beyond the Institution; MD Anderson in the Future
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD:
All right. Okay. Today is April 9th, 2014, and my name is Tacey Ann Rosolowski. And I am on the nineteenth floor of Pickens Tower today, interviewing Dr. Foxhall. This is our fourth session together. Thank you very much again for making the time—
Lewis Foxhall, MD:
Sure.
Tacey Ann Rosolowski, PhD:
—Vice President of Health Policy. And the time is about 12:58.
Tacey Ann Rosolowski, PhD:
And we’ve covered a lot of ground in three sessions. We really have. But I wanted to give you the opportunity, because last time we talked a lot about your role as vice president for health policy, and I wanted to find out what do you feel right now are some of the most pressing issues to address. We’ve talked about a whole variety of roles that you serve under the umbrella of health policy, but what’s really, really important and pressing for the institution and perhaps also for Texas?
Lewis Foxhall, MD:
The institution really is challenged in the area of access to care. This is not unique for MD Anderson or any large health center, but we continue to struggle in this country, and particularly in this state, to provide access to certain segments of the population, in particular those who lack healthcare insurance, who are low-income and can’t otherwise afford the wonderful care that we have here. So we have wonderful opportunities in treatment and prevention and participation in research trials that are provided through the institution, but not everyone can access it. So Texas is still the leader in the nation in the proportion of uninsured people, and that’s a problem, so we continue to work to find opportunities to collaborate with our elected officials and with other components of the healthcare system to try to address that problem. So we’re just beginning to see the initial effects of the Affordable Care Act, and it’s not totally clear how that’s going to impact things, but at least the early signals indicate that there may be some at least modest decline in the number of uninsured. So we’re hopeful for that. So it’s still a very politicized issue, and regardless of your political persuasion, it’s clearly important for us to get more opportunities for people to get the kind of care they need if they have cancer and apply those things that we know work out in the community to help reduce the incidence of cancer. So I’d say that’s really still our biggest challenge right now.
Tacey Ann Rosolowski, PhD:
And what would you like to see undertaken in the near future to help move ahead with that or with other issues that you find very pressing? I mean things that you’re not already doing.
Lewis Foxhall, MD:
Sure. Well, I think everyone’s doing everything they can. It’s a big problem and it’s going to take a lot of work to find a solution, but we have been hopeful that the changes with the Affordable Care Act could lead the way, and it’s just not clear right now if that’s going to happen here in Texas, because a large component of it has not been adopted with the use of the Medicaid program to provide care to more very-low-income individuals. So it’s still going to be a challenge, and we’ll continue to work with all of our partners and colleagues in the community and other [unclear] providers to do everything we can to be sure people are taken care of. So we’ll continue to work very closely with our colleagues and through the Harris County Hospital District and partner with the LBJ Hospital to care for people here in the immediate region and to provide access to low-income Texas residents to facilities through our Patient Assistance Program.
Tacey Ann Rosolowski, PhD:
Now maybe is the time to ask you about your role on the Texas Department of State Health Services Advisory Council, because I imagine that through that you really have a detailed look at what the situation is. When did you start in that role?
Lewis Foxhall, MD:
So it’s been about eight years now, I believe, I’ve been working with that agency and was appointed by the governor to serve on the council. This is the agency that includes what was formerly the state health department and also includes some of the agency functions that oversee behavioral health services for the state. So it has been a very interesting area to work in. That agency is a very large agency that addresses the public health needs of the state in terms of traditional public health surveillance, and that incorporates our Texas Cancer Registry as well as a number of programmatic areas that help to address public health risks, including problems such as tobacco and nutrition and physical activity across the state, and also includes work in the area of preparedness in emergency response that we certainly saw used during our major hurricane events here in the state. So it’s a very broad, wide-ranging agency, and our group is an advisory group. We get presentations on a regular basis related to any new rules or changes in procedures that the agency is considering, and provide input and take input from the public and then move those issues along to the Health and Human Services Commission, which has ultimate review authority in the state.
Tacey Ann Rosolowski, PhD:
Can you give me an example of a particularly intriguing or significant policy that you worked on through that committee?
Lewis Foxhall, MD:
Well, there are a number of important areas, so this includes policies related to tobacco control, which is an area I’m very interested in, and the agency receives funding for that program. So we get input on the strategic plan about how they intend to use the funding that they get and work with them as they develop their legislative appropriation requests when the legislature comes into session to see how much they’re going to ask for to fund the work that the agency does in that area. They also support programs on breast and cervical cancer screening, on nutrition and physical activity that are important risk factors related to cancer. So those areas are very interesting. It’s a very wide-ranging field of policies that they consider, so all the way from rabies control to emergency center operations and things like that.
Tacey Ann Rosolowski, PhD:
Have you learned anything unexpected from serving on that committee? Because I think you’ve been on it since 2009?
Lewis Foxhall, MD:
Yeah.
Tacey Ann Rosolowski, PhD:
Yeah. I mean, how has that broadened your perspective?
Lewis Foxhall, MD:
Well, it’s a good overview of the public health initiatives that the state’s engaged in. So to that extent, my focus has been primarily in the cancer arena, so it’s good to learn about the initiatives that are ongoing related to control of other big public health issues. And chronic diseases in the state have become more and more of a challenge, so things like cardiovascular disease and diabetes and other issues that are somewhat related to our cancer issues but a little different are interesting to hear about. So those are good. Other areas are childhood immunizations and things of that sort that they help work on. So it’s a very broad set of responsibilities that are required. The responses to these big challenges such as Hurricane Ike and Hurricanes Katrina and Rita that occurred were also very interesting areas that I’d not been involved in over the years, but they gave us input on how to get ready for those sorts of things and then how the response went when they had to deal with those sorts of occurrences. So, interesting stuff.
Tacey Ann Rosolowski, PhD:
Yeah, very interesting. Was there anything that you felt you learned that you could bring back to your work on health policy that’s focused on cancer? I’m just curious about those lateral moves.
Lewis Foxhall, MD:
Yeah, well, cross-platform issues, I think, is really more the general approach to the administration of public health-related laws. I think that’s interesting. So the agency is really charged with implementing legislation that is passed by our elected officials during the legislative sessions, so they don’t necessarily come up independently with their own agenda, but they tend to interpret the laws that are provided to them by the legislature and try to apply them to get the most effect for the citizens here in the Lone Star State. So that’s kind of the way it works, but, anyway, it’s an interesting process.
Tacey Ann Rosolowski, PhD:
Kind of back to more general issues but more related to cancer, are there particular challenges that you see coming with changes in healthcare, anything that you feel this office is preparing itself for?
Lewis Foxhall, MD:
Well, a number of the issues are things that are really extensions of the challenges that we see now, so in trying to think ahead to how we can best provide treatment and preventive services, a lot of the issues revolve around funding, and this is an evolving process right now. So as the payment system is slowly being changed from the traditional fee-for-service arrangement where clinicians and institutions like ours are paid for doing things, no matter how many things we do, to one in which it’s based on value, quality of care, and outcomes of care is a big change, and trying to understand how to best position the institution and our clinicians to deal with that is a big challenge. But that whole area is going to change and it has to change, and we’re just trying to best understand how we can connect with these new sorts of payment arrangements and different ways to manage the cost of not only care, but also provision of preventive services is a big challenge.
Tacey Ann Rosolowski, PhD:
Are there some specific solutions within that arena that you’re beginning to think about now?
Lewis Foxhall, MD:
Got it all figured out.
Tacey Ann Rosolowski, PhD:
You got it all figured out. Well, share. (laughter)
Lewis Foxhall, MD:
There are many possibilities. I think we’re trying to look at different approaches, and other people in the institution, of course, are really heavily involved in this as well. So, trying to think through what value-based care means and how we can apply it, what we can do here in the institution to help reduce the cost of the care that we provide, while maintaining or even improving quality in patient satisfaction are very complex and challenging issues. So we have a very large and complicated delivery process here that’s not all that easy to really change the way we do things, and it’s not exactly clear when we should make a change either. There’s still, you know, the vast majority of payments are still on a fee-for-service sort of basis. But as that changes, as more organizations that are driven by value-based payments, like accountable care organizations and different value-based payment demonstrations [unclear] are allowed, then we have to be able to position ourselves to try to take advantage of those situations, or at least not be harmed by them in a financial way.
Tacey Ann Rosolowski, PhD:
Now, as I understand it, there’s actually been a lot of discussion about what exactly value-based care means. I mean, how do you establish, quantify that? And can you enlighten me a bit now? What is your understanding of what that phrase means, maybe in the abstract but also to MD Anderson?
Lewis Foxhall, MD:
Well, I think in general it’s the idea that the public and the federal government or the entity that’s paying for care wants to have some assurance that it’s getting its money’s worth. So the idea that we need to be able to measure and document the outcomes of care and the processes of care more than just the volume of care, and the payment based on that is really the big change [unclear]. So this has been under development for a long time, and things are slowly beginning to change as we think about how things move forward. But the big overriding principle of this is really what’s sometimes called the triple aim of improvement, and that’s to improve the quality of care while reducing the cost of care and increasing the level of satisfaction of the course of care by the patient. So some people say there’s a fourth thing which ought to be one related to equity, that everyone in the population should be able to access that value generated by that change. So it’s rather than just continue to do business as usual, continuing to do today what we did yesterday, is not going to work as we look at the continually rising costs of our expenditures on healthcare, and the growing proportion that healthcare absorbs of the total budget of the country is continuing to increase year over year, and that just can’t be maintained. Meanwhile, other concern that at least by the measure of how long we live, the country is not at the top of the heap. So our numbers are middling at best. So people have begun to ask about that. The federal government has driven a lot of this. They’ve seen their costs related to the Medicare program, in particular, rise over time. The vast majority of healthcare expenditures is related to the relatively small number of chronic diseases that people do suffer from them, so that we are dealing today primarily with these noncommunicable diseases rather than infectious diseases that have traditionally been the big problem in decades past.
Tacey Ann Rosolowski, PhD:
Interesting.
Lewis Foxhall, MD:
So these are all things we can manage. They are things, however, that tend to cost a lot of money to fix or to maintain, and it’s a big challenge. So we see great progress in the research that we’re doing, particularly in cancer, has yielded wonderful new treatments, targeted treatments that are able to treat disease very effectively with relatively lower side effects, but all these new treatments are very expensive, so we’re trying to understand how we can pay for those and get them to everybody who can benefit from them is difficult. So there’s a lot of thought going on into how we can go about approaching that.
Tacey Ann Rosolowski, PhD:
I just wanted to ask you for a clarification. When you were going through the triple aims, I was kind of surprised at number three, which was increase the level of satisfaction, and I thought, wow, why isn’t it increase the effective outcome? So what was the choice there, talking about satisfaction as opposed to outcome?
Lewis Foxhall, MD:
Well, outcomes is one [unclear].
Tacey Ann Rosolowski, PhD:
Outcomes, okay, okay.
Lewis Foxhall, MD:
So improved outcomes, reduced cost, and improved patient satisfaction with the experience of care. So it’s not intended to, you know, be better and cheaper, but [unclear]. (Rosolowski laughs.) So it’s trying to find a balance there between the clinical outcomes and the patient’s perceptions of getting there. So that’s really sort of the discussion that’s gone on for some time, and Don Burwick [phonetic] and folks of that sort have been talking about this for some time and have gradually been incorporating that into some of the policies, primarily with the Medicare program, over time to help sort of change the way we think about things.
Tacey Ann Rosolowski, PhD:
Very complicated situation.
Lewis Foxhall, MD:
It can be.
Tacey Ann Rosolowski, PhD:
Yeah. I’m just thinking, wow, lots of sleepless nights.
Lewis Foxhall, MD:
The principles are fairly straightforward, but how you get there is kind of tough.
Tacey Ann Rosolowski, PhD:
How you get there, yeah. How you get there.
Recommended Citation
Foxhall, Lewis E. MD and Rosolowski, Tacey A. PhD, "Chapter 17: A Major Challenge: Serving the Uninsured as Health Care Changes" (2014). Interview Chapters. 866.
https://openworks.mdanderson.org/mchv_interviewchapters/866
Conditions Governing Access
Open
