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Why aren't presidential candidates talking about value-based care?

Last night, an important missing piece of the health insurance conversation came from an unexpected source.

Democratic presidential candidate former tech executive Andrew Yang speaks during the Democratic Presidential Debate at Texas Southern University's Health and PE Center on September 12, in Houston, Texas. (Photo by Win McNamee/Getty Images)Democratic presidential candidate former tech executive Andrew Yang speaks during the Democratic Presidential Debate at Texas Southern University's Health and PE Center on September 12, in Houston, Texas. (Photo by Win McNamee/Getty Images)

If you had asked me before the start of last night's Democratic debate which of the 10 candidates would have the most insightful soundbite on healthcare, I think I would have had nine answers to give you before I got to Andrew Yang, the entrepreneur who has run a largely one-note campaign based on the notion of a universal basic income.

Yet toward the end of the three-hour spectacle, I was shocked to hear Yang become, to my knowledge and memory, the first candidate in any of the three debates to allude to a topic that those of us immersed in the healthcare finance industry discuss every day: value-based care. 

"Now, I am Asian, so I know a lot of doctors, and they tell me that they spend a lot of time on paperwork, avoiding being sued and navigating the insurance bureaucracy. We have to change the incentives so instead of revenue and activity, people are focused on our health in the healthcare system," Yang said. "And the Cleveland Clinic, where they're paid not based upon how many procedures they prescribe -- shocker -- they prescribe fewer procedures, and patient health stays the same or improves. That is the pitch to the American people."

I cleaned out my ears. Since the beginning of these debates, I have marveled at the divide between my professional circles, where it's more or less a given at this point that the road to lower costs is by changing incentives, and the public sphere, where all of the conversation is about who pays for healthcare and how, and none of it addresses why it's so expensive in the first place and how we can bring that cost down. Value-based care, which includes a number of different specific models, is an umbrella term for the notion that we can lower healthcare costs when payers and individuals pay providers for outcomes (healthy people) rather than being billed for each procedure, test, visit, and surgery.

Last month I took to Twitter to confirm that I wasn't alone in my observation of this disconnect. This is what I tweeted, using Twitter's poll function:

"People who work in or around healthcare: Are your non-healthcare friends and family aware of value-based care as a concept and a potential solution to rising healthcare costs? Or is it something we only talk about in our professional bubble?"

Only 13 people responded, but they unanimously voted for "No, it's bubble-only."

This isn't a moot point. Another minor candidate for the Democratic nomination, former Maryland Congressman John Delaney, got at it from another angle back in the first debate.

"If you go to every hospital in this country and you ask them one question, which is 'How would it have been for you last year if every one of your bills were paid at the Medicare rate?' every single hospital administrator [would say] they would close," he said. "And the Medicare for All bill requires payments to stay at current Medicare rates. So to some extent, we're supporting a bill that will have every hospital closing."

Prior to Yang's comment, that's the closest I heard anyone come to acknowledging that Medicare for All is a debate about who pays for our care. And while that is a politically convenient talking point, and perhaps one that lands better with struggling families, it's fundamentally short-sighted. Without a conversation alongside it about how to make care affordable, any single payer proposal opens itself up to very reasonable criticisms like Delaney's.

If you dive deeper into the candidates' plans, you can find occasional nods to value-based care and changing incentives. Sen. Kamala Harris, for instance, proposed a "Medicare Advantage for All" plan, evoking the Medicare offshoot which uses capitated, rather than fee for service, reimbursement. But even then, the focus was not on the possibilities for value-based care, but on the fact that Medicare Advantage leaves room for private insurers to continue existing, rather than abolishing them as "Medicare for All" might.

We can't afford for value-based care to be the best-kept secret of healthcare pundits and policy wonks. It needs to be a centerpiece of how we all think about reducing the out-of-control healthcare costs in our country, and the 2020 presidential debates provide a rare public forum for these ideas to get out into the mainstream. 

It's a shame that it took three debates and an outsider candidate to bring it up.

Twitter: @Jonah Comstock
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Jonah Comstock is the director of Content Development and editor in chief for HIMSS Media, the media group that includes Healthcare Finance News, Healthcare IT News, and MobiHealthNews. He has covered digital health for the past seven years.