Health care policy experts gathered for a panel discussion at the AcademyHealth National Health Policy Conference on Feb. 11 to tackle how we can more effectively spend our health care dollars and understand possible tradeoffs.

The panel, moderated by National Pharmaceutical Council (NPC) Chief Science Officer Robert Dubois, featured Stacie Dusetzina, associate professor, Vanderbilt University; Katie Martin, senior fellow, Health Care Cost Institute; Michael Thompson, president and CEO, National Alliance of Healthcare Purchaser Organizations; and Joel White, president, Council for Affordable Health Coverage (CAHC).

“We need to have difficult conversations about the tradeoffs,” said White. “We’re spending a lot but getting little in return. I love the fact that we are here to talk about uncomfortable things.”

During their conversation, the panelists took a deeper dive into some of the more challenging issues with health spending facing policy stakeholders today. They pointed to the growing burden of out-of-pocket costs on patients, wage constraints, wide cost variations both within and between markets, and payment structures.

Another challenge to managing health spending is that many of the financial incentives in the health care system are misaligned, noted Dusetzina. She explained that when Medicare greatly reduced the price it would pay for CAR-T, a cancer therapy, this incentivized hospitals to either not treat patients using CAR-T or administer the therapy on an outpatient basis, “which discriminates against patients in poor health.”

Thompson agreed. While there has been some progress toward paying for value, there are rewards for “doing the wrong thing in the health care system.” Both Dusetzina and Thompson said this misalignment is why so many policymakers are looking at a public health insurance option, because it would allow a greater pool of resistance against higher prices and “wrong” incentives.

When it comes to reining in costs, Dubois asked the panelists who in the system should be saying “no” to spending on an expensive procedure or treatment – providers, patients, payers?

White noted that there are numerous “no” decisions being made throughout the U.S. health care system, such as an employer deciding on coverage options, an insurer denying payment based on their contracts or the federal government declining to cover procedures in certain health programs. Dusetzina said that who can say “no” might “depend on the type of technology you are talking about,” and sometimes the most effective group could be physicians. Physicians could say no to using a specific treatment or procedure until the price comes down, she said.

Martin suggested the question needed to be reframed – that it “isn’t about saying ‘no’ to patients to getting what they need. There are a lot of other ‘nos’ to go around, as in, we’re not going to pay you that much for a drug or procedure. We need to talk about those ‘nos’ for reining in the system instead of saying ‘no’ to patients,” said Martin.

They also discussed financial incentives for patients and their mixed results in encouraging better outcomes. Low- or no-cost sharing approaches, which are intended to lower access barriers to high-value or necessary care, have not worked as well as expected, nor have high-cost sharing approaches, which are aimed at deterring the use of low-value, or unnecessary treatments.

Martin stressed that despite the use of financial incentives for patients, there are often other reasons why patients aren’t able to access the care they need. Social determinants of health are among those important factors, she said.

Panelists acknowledged that there are more questions to be answered than time allotted for the panel, a point that was echoed by audience members. They raised concerns about other topics that should be addressed as part of how we spend our health dollars: “whether we will have the courage to talk about the H word – hospice” and whether we have the “political muster” to include it in conversations about patient care. Additionally, they asked about the interest in really talking about “family caregivers, both paid and unpaid, without whom our health care system would collapse.” Audience members also noted that it’s hard to have this type of honest dialogue on social media and welcomed ongoing conversations about difficult health care questions.

Although the panel time was limited, the conversations on health care spending are continuing, led in part by the Going Below The Surface Forum, a group of 20 diverse organizations. NPC, the National Alliance and CAHC are Forum partners.