Coordinated Care Systems and the Brave New World of Healthcare Delivery
Many of you are out in the field having involved conversations now with your plan sponsors anticipating January renewals. Most business owners are stressed by the recession and more are ‘getting it done’ with fewer employees uncertain about what the future will hold. Without exception, business owners are worried about what health care reform will mean to them. In the short term, health plans are raising rates to accommodate the mandates of new reform provisions. In the long term, we are seeing health plans start to talk about and even implement tiered networks which accentuate the value of certain preferred provider or ‘accountable’ groups including doctors and hospitals. Limited networks are likely a ‘new’ reality.
If we look to Massachusetts we see a model in distress. Many highly rated health plans are financially distressed by the mandates of health reform. While universal coverage has taken hold…..healthcare costs have risen well above the national average. More importantly, the health care delivery infrastructure has been besieged (and some will say overwhelmed) by too many bodies with too few primary care physicians. The reality is that if you don’t have a PCP in MA now…..you probably won’t be able to get one. Many provider organizations are scurrying to scale their organizations through the recruitment of para-professionals. If you need a PCP visit NOW….you’re going to have to wait an average of 40-60 days for a visit. Massachusetts emergency room visits are up nearly 15% year over year as a result of this infrastructure deficiency.
Cost pressures in MA have the players pointing fingers at one another. The legislature has talked about realigning costs and payments in the system via ‘accountable care organizations’. These arrangements would get rid of fee for service and replace it with ‘global payments’. National healthcare reform wonks have talked about these payment realignment strategies for a long time as they simultaneously talk about the utility of the medical home model for PCPs, the install of EMR/EHR technologies in physician offices and the creation of a national digital infrastructure for providers to exchange patient data between providers in a ‘meaningful’ way via Health Information Exchanges. Again, the reality is that all of this change requires time and money. Electronic repositories and data bases don’t magically reduce costs and decrease errors. Primary care physicians are already overwhelmed by the new glut of patients. New record keeping technologies are expensive and disruptive to providers as they try to carry out their duties and learn new operations. There is no clear or consistent path to resolve these ‘coordinating’ issues.
In short, those who are involved in purveying health coverage to employers owe it to themselves to get ahead of the curve. Employers MUST get to their employees now to encourage them to secure a primary care physician. PCPs are the first line of defense for members in screening against disease process and in terms of providing continuous care. Healthcare via disjointed clinics and ERs does not provide continuity. New preventive guidelines allow members to get screened annually….one of the surest means for staying away from expensive catastrophic claims. A group with PCP ties is more likely to be predictable and educated. It is clear that healthcare cost pressures will likely lead to continued conflict between all of the players in the system…….members, payers, providers and government. Members who are part of the system now (have a provider) will likely derive more value from a reformed system than those who are not part of the system (and end up struggling to get a provider later). It is important that utility to members now.
Follows are two links describing the movement to a coordinated care system and a piece that describes accountable care systems and global payments in Massachusetts as described above. You owe it to yourself to understand the brave new world of healthcare delivery. Your plan sponsor deserves to know what is coming…………
http://healthblawg.typepad.com/healthblawg/
http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/medical-homes.aspx
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