How are clinicians integrated into the health insurance industry?
The health insurance industry has formed alliances with health care organizations to the benefit of both sides. By creating an integrated system that involves physicians, hospitals and other providers, they are able to create a system of quality care that is responsive to the needs of its members.
Clinicians can also work with insurers to provide a high level of care after a patient is discharged from the hospital. Often, instructions are issued at a time when the patient is not at his or her best, and if a caregiver is unavailable to take notes and follow through with the instructions, those instructions may simply not be followed.
By working with the insurer to provide health managers after discharge, clinicians can help speed the rate of recovery and lower the number of patients who are readmitted after relapsing due to a failure to follow instructions.
In addition, Accountable Care Organizations are a recent trend, in part because the new health care reform law requires that the model be set up for beneficiaries of Medicare by January 1, 2012. Contrary to popular belief, clinicians who order more tests and whose patients spend more money on health care don’t necessarily achieve better outcomes. To address this, ACOs change the focus of health care to reward clinicians for providing high-quality care. The idea of ACOs is to encourage doctor groups or hospitals to work together instead of working independently to oversee the care of patients so that quality goes up and costs go down.
Under this model, instead of being paid by the quantity of work they perform, they are instead paid for quality outcomes and managing costs. In return for their cooperation in lowering costs and improving care, the provider may receive a share of the resulting savings.
This model encourages clinicians to not only focus on treatment when someone is ill but on prevention of an illness in the first place, giving them an incentive to keep their patients as healthy as possible.
What is the value of integrating clinicians in this manner?
By integrating clinicians into the process, patients receive a higher quality of care. As a result, lengths of hospitalizations decrease, as does the rate of readmission, saving on costs both for the health care consumer and the insurance company.
Clinicians also benefit through access to best practices, allowing the insurance company and the provider to work together to create a patient-centered, integrated health care system. By working together as a team, they can improve outcomes, resulting in a healthier and happier population.
MARTY HAUSER is the president of SummaCare, Inc., a provider-owned health plan located in Akron, Ohio. SummaCare offers a full line of health plans and ancillary products. Through its extensive network of more than 7,000 providers and more than 50 hospitals, SummaCare offers coverage to more than 115,000 members throughout northern Ohio. Reach him at [email protected].
