Ten months ago, we wrote about Health and Human Services nominee Tom Price and suggested topics for the Senate to explore in his confirmation hearings. No one guessed that after being confirmed he would fall from grace and resign so quickly. There is now a second nominee, Alex Azar. While Azar may be less contentious than Price, there are public health questions — beyond the expected, predictable, and political grandstanding by both parties on the Affordable Care Act — that the Senate should ask.
Based on Azar’s educational and professional background, there is little doubt that he is qualified for the position. He is a well-qualified and experienced lawyer with significant previous executive branch experience. Some may question his potential conflicts around drug pricing due to his leadership role in a biopharmaceutical company — Eli Lilly and Co. While we do not have a crystal ball about what he might or might not do in the future about drug prices we do know that he will have to act on some key public health issues. So, here we focus on those challenges. Specifically, three issues he cannot avoid:
First, the Senate Health, Education, Labor and Pensions Committee should find out Azar’s views on advancing payment reform. Under fee for service, providers have strong incentives to do more and sometimes to over treat. Fortunately, there are proven alternatives, including Accountable Care Organizations, bundled payment systems, and pay for performance approaches that are proven to reduce cost growth and improve quality. These innovative approaches were not invented by former President Barack Obama, but rather are derived from work done in the private sector, incentives authored by the Bush administration and pilot programs encouraged by Obama under the ACA.
Price seemed allergic to these new models, even filing suit against bundled payments as a member of Congress. We hope that Azar commits to working with all stakeholders to lead our health care payment schemes into the 21st century. We also hope that he commits to designing these models so that they are workable for independent physician groups. Early experience has been resounding that independent physicians and small groups have been more effective at saving money and improving outcomes. Supporting independent physicians will also help mitigate the market power of health systems who already employed or acquired about one quarter of all physicians.
Second, how will a Secretary Azar reform the process of granting Medicaid waivers? Here is an opportunity for the new administration to expand access to health insurance, but to do so with consumer protection safeguards using business models that are innovative or unique. At this point the question should not be over politics, but about policy. Each waiver will need to meet the letter and intent of the law. But, equally important, the waiver process should become a testing ground (or in the Jeffersonian sense, a “laboratory of democracy”) for new ideas and payment models to improve quality and lower costs.
Third, nominee Azar should be asked detailed questions about the implementation of the administration’s plan on responding to the opioid crisis. Most important, who inside the White House is responsible and accountable, what specifically is the goal of the plan, and is the plan funded sufficiently to achieve the goals? Thus far, the Trump team has offered no concrete plan and no funding for implementing the recommendations of the Christie Commission.
We don’t care if the coordinator is called a “czar,” but someone needs to be in charge and they will need funding. There are too many agencies with assets that need to be deployed against the scourge of opioids beyond HHS to leave implementation to separate agencies. This will lead to uncoordinated action and far less impact. The good news is that a strong start on an action plan has been laid out by National Institutes of Health Director Francis Collins and Food and Drug Administration Commissioner Scott Gottlieb, but more needs to be done by the Centers for Medicare and Medcaid Services and the Surgeon General. Beyond HHS, more leadership can come from the Defense, State, and Justice departments. Setting up aspirational goals like the opioid commission is a good first step, but a single accountable White House official must be empowered to integrate and supervise the conflicts that are inevitable when more than one agency must act.
The Senate confirmation process is more than a vote up or down on a person and their qualifications. Rather, it is an opportunity for the Senate to express its priorities about public health for the next three plus years of this administration. Our plea to the Senate is to make your voice heard and to insist on results rather than rhetoric.
Bob Kocher, who previously served as special assistant to President Barack Obama for health care and economic policy, is a partner at Venrock and a consulting professor at Stanford University. David Beier served as chief domestic policy advisor for Vice President Al Gore and is a managing director of Bay City Capital, a health care venture capital firm.