A recent article in the Journal of the American Medical Association (JAMA) documented a trend that health care providers and consumers have noted for several years — consumers desire choice in their health care insurance coverage.
For the past 20 years, insurance carriers have attempted to influence the demand side of the health care purchase equation by trying to modify physician practice patterns. These attempts have ranged from capitation to exclusive provider networks to medical management. But, reports JAMA, “the health plans discovered that patients often did not appreciate managed care initiatives, which they interpreted as efforts to save money rather than improve access and quality.”
In response to the criticism — and the poor reputation that these managed care efforts received — insurers are now attempting to reposition themselves as agents of the employee rather than of the employer.
In the 1990s, a popular strategy with insurance companies and some providers was to offer exclusive contracts. While these contracts may have offered employers and employees coverage with their most preferred providers, it happened at the expense of the doctors and hospitals, which received minimum reimbursement rates for the benefit of exclusivity. As consumers began to request access to multiple providers, exclusivity no longer made sense.
As a result, today’s consumers have access to a variety of providers, and choosing can be a daunting task. In the United States, health care quality has not been defined in a way that is acceptable to providers, payers, employers and consumers. Yet a growing number of rankings and ratings tools are being made available to the public, including clinical outcome measures (U.S. News and World Report, Healthgrades and Solucient) as well as the management measures included in Solucient.
Other tools, such as the AARP methodology, have not achieved the same visibility. Research suggests that these tools, particularly U.S. News and World Report, are beginning to pick up traction with consumers. A 2003 VHA (a national association of more than1,000 hospitals and health systems) study showed that 31 percent of consumers looked for quality ratings for doctors or hospitals in making decisions about where to go for care.
As an employer, you may be faced with the challenge of making sure that your insurance carrier includes a certain provider or you may be selecting a physician or hospital for yourself. Although quality data can be confusing, try to make sure that you are comparing apples to apples. In many cases, Medicare data is used because it is publicly available; however, it tends to be for older patients and is based primarily on inpatient services.
The most basic and official credentialing agency for hospitals in the United States is the Joint Commission of Health Care Organizations. Hospitals undergo this credentialing process every three years and receive a numeric score based on their ability to meet set standards. For physicians, the gold standard is board certification in the specialty practiced.
More important, consider volume and outcomes. More than 300 studies have been completed and published showing that there is a very strong relationship between high volume centers and better patient outcomes. This relationship is probably due to the old adage “Practice makes perfect.”
Employers can use three basic principles to make sure the insurance carrier they use offers coverage by the best providers.
1. Numerous studies published in the medical literature have shown that high volumes and lower mortality rates assure the best quality. Study available data, but select based on these criteria whenever possible.
2. Larger, national groups or rating systems are more likely to have achieved provider and employer consensus on data than are local groups.
3. Ensure that your employees have appropriate geographic coverage as well as access to the breadth and depth of services needed.
As questions come up and data requires explanation, never hesitate to ask your physician or hospital about their volumes and results. A quality-oriented provider will always be willing to share its results and provide a comparative explanation. Dr. Richard J. Streck is senior vice president of medical affairs for Akron General, a position he has held since arriving at the hospital in 1997. He previously was chairman of the Department of Medicine at Good Samaritan Hospital. Reach him at (330) 344-6000.
