Updated November 27 at 12:27am

Outcomes, network access will define care in future

Guest Column:
Jim Purcell
The recent news about UnitedHealthcare of New England’s termination of physicians from its participating network for Medicare Advantage shows that more than just healthcare.gov has the potential to inflame public passions.

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Outcomes, network access will define care in future


The recent news about UnitedHealthcare of New England’s termination of physicians from its participating network for Medicare Advantage shows that more than just healthcare.gov has the potential to inflame public passions.

Let’s consider the issue:

• True health care delivery reform will require some disruptive measures.

• To reform health care delivery, we must change how we pay for it, and pay on the basis of quality of care and outcomes – not on the number of things done. Thus, if our delivery of health care results in demonstrably better quality and outcomes, the total cost of care will lessen over time.

• Contrary to the current public debate, it’s not about cutting care, but instead it’s about achieving better health through better care. Even if costs aren’t cut, at least we will have a better product.

• We do not yet have established measures of quality of care, much less outcomes. Once we do, we need physicians, hospitals and other providers to agree to abide by them.

• Over time, then, health insurers will change how they pay providers based on those quality measures. Physicians and other providers who agree to be paid by those measures would be in that insurer’s “network.” This would be a high-quality network, one that a smart buyer would want to belong to.

• Once we have such a network, we have to hold those providers accountable for better care and outcomes.

So far, unfortunately, that is not how the concept is playing out. Under the Center for Medicare and Medicaid Services’ version of accountable care organizations for Medicare, patients can decide to use providers other than those in that ACO’s network. This is unfair in the extreme. How can we hold providers responsible for outcomes if they don’t control the care of the patient, and if the patient can use any physician they want regardless of quality?

The same is true regarding electronic medical-record use. Physicians who refuse to use electronic medical records disable themselves from participating in this type of network.

So what to do? First and foremost, we must establish and agree on measures of quality and outcome. And once we do, we have to start measuring them, physician by physician, hospital by hospital, etc.

As we develop the data, we then place physicians, hospitals and other providers in “tiers” based on quality and outcome. This won’t be a pleasant experience for anyone, but it has to be done. We will have to develop a dispute-resolution mechanism that is inexpensive and speedy (fast-track arbitration?), for surely there will be some disagreements on provider tier placement.

Next, we enable the “quarterback,” namely the primary-care physician. We don’t have to exclude any provider from the network, but there will be consequences if patients choose say a tier 3 (worst in quality and outcomes) surgeon.

Insurance-plan design would create deductibles based on the tier. Tier 1 (best) is, let’s say, no deductible; tier 2 (mid level) is a $500 deductible; tier 3 is a $2,000 deductible.

It’s a free world so to speak, and you can choose a lower-quality physician (perhaps one highly recommended by your aunt), but there will be consequences.

This benefit design will finally give the PCP an effective tool in referring her patients to higher-quality providers. In turn, since a significant portion of the PCP’s income will be based on quality of care and outcomes of her patients overall, she will very much want to refer only to top-quality providers. By the foregoing, we become aligned, but the key is giving PCPs and patients the data and the plan design to enable them to refer to or choose quality.

We are mindful of the very important physician/patient relationship, and the difficulty encountered if one has to change physicians. We also are mindful that continuity of care of ongoing conditions is important. These can be dealt with.

But the hard message is that over time, complete freedom of choice without consequences will disappear. This cannot happen in a year or two; much needs to be done. But everything drives off the quality of care and outcomes data, and accountability.

The fruits of our labor

If we can accomplish the foregoing without too many lawsuits, screams of anguish, media and political forays, etc., what changes will follow? For one, we finally put the competition at the right level.

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