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Quality and Pricing Transparency from a Payor

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Four Cornerstones of Value-Driven Health Care: ... Mitigate increases in medical trends through consumerism by identifying and selecting physicians ... – PowerPoint PPT presentation

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Title: Quality and Pricing Transparency from a Payor


1
Quality and Pricing Transparency from a Payors
Perspective
Bill Fried, M.D. Medical Director MidAtlantic
Region Aetna
2
  • The Changing Health Care Environment
  • Consumerism
  • Price Transparency
  • Quality Transparency
  • Consumer Decision-Support Tools

3
The Financial Projections
The Changing Health Care Environment
4.6 Annual Growth Rate in Household Income
12 Annual Growth Rate in Health Insurance
Premiums
68,277
48,769
34,836
24,882
17,773
12,695
9,068(1)
19
23
28
34
42
51
63
Health Benefits as a of Total Compensation
(1) Projected 2003 Average Health Insurance
Premium for Family Coverage Source Kaiser/HRET
Survey of Employer-Sponsored Health Plans, Bureau
of Labor Statistics 2003 National Compensation
Survey
4
Percentage of U.S. Firms Offering Health Coverage
Source Kaiser/HRET Survey of Employer-Sponsored
Health Benefits 2000-2005
5
Executive Order on Transparency
  • August 2006 President Bush signed Executive
    Order on Transparency
  • Requires federal health programs to make health
    care quality and cost transparency information
    available to consumers
  • The Four Cornerstones
  • Support Health Information Technology
  • Provide Quality Information
  • Provide Pricing Information
  • Promote Quality and Efficiency of Care
  • More information available at
    www.hhs.gov/transparency

6
American Medical Association statement on
Executive Order
  • "Today's Executive Order is a step toward
    increased price transparency in the health care
    system. However, gone are the days when a doctor
    posts fees and patients pay the doctor directly.
    Now, it's third-party payers insurers and the
    government who set prices. If we want patients
    to become more prudent purchasers of health care,
    they need to be in greater control of their own
    health insurance choices and decisions, and need
    price transparency from all insurers not just
    the federal government.

7
Four Cornerstones of Value-Driven Health Care
Health Plans Responses
  • Support Health Information Technology
  • Personal Health Records
  • Physician incentives to increase use of
    electronic services
  • Provide Quality Information
  • High Performance Networks
  • Hospital Comparison Tools
  • Leapfrog Group Hospital Quality and Safety Survey
  • NCQA accreditation
  • NCQA Physician Recognition Programs

8
Four Cornerstones of Value-Driven Health Care
Health Plans Responses
  • Provide Pricing Information
  • Physician-specific pricing
  • Average cost information for a variety of
    office-based, ambulatory, and inpatient services
    and procedures, drug costs, and episodes of care
  • CMS posting of rates for elective inpatient
    procedures and common hospital admissions
  • Promote Quality and Efficiency of Care
  • Support of Leapfrog Groups Never Events policy
  • Care Focused Purchasing initiative, which focuses
    on the quality and efficiency of health care
    providers
  • Pay for Performance programs
  • Bridges to Excellence program

9
Consumerism
Consumerism
  • Individuals will have more responsibility for
    health decisions will pay more of costs
  • Content, tools, programs and services to
    encourage smarter, informed decisions
  • Requires individuals to acknowledge that they
    each have a personal responsibility in achieving
    optimal health care outcomes

10
Placing the Patient at the Center
  • HDHP, HRA, HSA plans
  • Decision tools for value-based purchasing
  • Performance networks
  • Personal Health Record
  • Health incentives
  • Health care transparency
  • Integrated medical management
  • Wellness programs
  • Effective communications and education

11
Do Consumers Really Understand the Cost of Health
Care?
Consumer Perceptions vs. Reality of Medical Costs
Source Lehman Brothers, Health Insurance
Consumerism, May 2006
12
Price Transparency
  • Actual negotiated rate available to consumers
    before they receive care
  • Via secure website, members can access doctors
    rates for up to 30 different services most
    commonly delivered by that physicians specialty
  • Rates appear in 5 categories office visits,
    diagnostic services, minor procedures, major
    procedures and other services

13
Price Transparency Rates Available to Members
View Rates for the Selected Doctor
14
Price Transparency Rates Available to Members
(contd)
15
Consumer Research How Do People Select
Facilities?
How do you decide which hospital or facility to go to? 1st Choice ( of respondents)
Covered by my health insurance plan 40
Doctor recommends 26
Best reputation for quality in the area 16
Highly recommended specialists admit there 9
Most conveniently located 5
Other 4
Recommended by family or friend -
Least cost 0
16
Do Consumers Really Understand the Site of
Service Cost Differences of Health Care?
  • Radiology and Diagnostic Imaging Average Cost per
    Unit

17
Consumer Research What We Have Found
  • Consumers like the idea of site of service
    transparency
  • Information in one online location, ability to
    match right facility to medical condition,
    convenience, and peace of mind
  • Searching by site location or by name of health
    care professional depends on the procedure type
  • Relatively high risk (e.g., cataract eye surgery,
    cardiac catheterization), consumers prefer
    searching by physician
  • Relatively low risk diagnostic procedures (e.g.,
    CT scans, sleep study), site location is
    preferred method for searching

18
Procedure-Based Site of Service Tool
  • Facility-specific information not regional
    averages
  • Includes ambulatory and inpatient facility types
  • Reasonable bundle of services for the procedure
  • All costs included
  • Range of costs based on payer claims experience
  • Costs are broken down into two categories
  • Managing physician charges
  • Facility Ancillary charges combined (medical
    supplies, laboratory, etc.)

19
Procedure-Based Site of Service Procedures
  • Elective services where people are more likely to
    consider their out-of-pocket costs
  • Common and familiar to consumers
  • Planned for by a consumer
  • High volume
  • Multiple options for locations to seek care
  • MRI, CT scan, colonoscopy, common maternity and
    cardiac procedures are a few examples of
    procedures that are available

20
Medical Procedure by Facility Cost - Search on
Procedure
21
The Current System Needs Improving
Quality Transparency
  • Quality reliability
  • Average patient has 50 chance of getting the
    right care at the first physicians visit
  • Health care inefficiencies
  • The right treatment
  • The right delivery
  • 40 opportunity to improve costs
  • Public perceptions about health care
  • 42 say they, or a family member, experienced a
    preventable medical error
  • Consumers not using quality data
  • Shuster (Rand)
  • Wennberg
  • Kaiser Family Foundation

22
Consumers Want Information on Physicians/Hospitals
Types of Information Health Plans (Provide)
Doing Now
Not Doing/Want
Not Doing/Don't Want
58
36
6
Info. to choose best plan
55
34
11
1-800 RN/med. prof. hotline
35
52
12
Providing Info. on best MDs/hospitals
Working hard to keep me
34
48
18
well
29
46
25
Making sure I get tests I need
Ensuring all my MDs have
26
47
27
current Rx info
23
44
23
Full info. on meds/alt. meds
Helping with Q's to ask/tests
20
45
35
to be done
Source Consumer Habits and Practices Study, 2005
23
New Health Care System
Health Care Professionals
Information Accountability
24
An Approach Whose Time Has Come?
  • Mitigate increases in medical trends
  • through consumerism
  • by identifying and selecting physicians
  • responsible for significant portions
  • of health care spending who have met
  • certain thresholds for clinical performance
  • and effective use of health care resources

25
High Performance Networks
  • Subset of broad network
  • High numbers of physicians within each specialty
  • Responsible for high dollars
  • Measures available to allow for differentiation
  • Significant variability in efficiency and quality
  • Sufficient claims experience for credible
    analysis
  • Viability of new network

26
High Performance Networks Caveats
  • Significant employer commitment
  • Collaboration with physicians
  • Clinical and efficiency measures externally
    validated using established national standards
  • Rankings not based solely on cost
  • Disclosure to physicians and consumers
  • Measures understandable and meaningful to
    consumers
  • Independent oversight

27
Designation Evaluation Process
High Performance Networks Designation Process
Criteria Type Measure
Volume Symmetry Episode Treatment Group (ETG) At least 20 episodes of care over 3 years
Clinical Performance All specialties measured on the following Adverse events during inpatient hospital stays 30-day unplanned hospital readmission rate Measures applicable to obstetricians/gynecologists Cervical cancer screening rate Breast cancer screening rate HIV testing in pregnancy Measures applicable to cardiologists Beta blocker use after cardiac event ACE inhibitor (or ARB) use in patients with congestive heart failure Use of cholesterol-lowering medication (statin) for members with cardiac disease
Cost-Efficiency ETG efficiency index (percentiles), relative to regional norms
Network Adequacy Verify final network satisfies established access standards
28
Stakeholders in Performance Improvement
29
Quality Transparency Available to
Members Physician met all standards
30
Quality Transparency Available to Members
Physician not meeting volume
31
Driving Improvement Opportunities Virginia Mason
Medical Center
  • Collaborative relationship with high quality,
    nationally respected health care system
  • Employer support
  • Collaborative experiment created
  • New clinical pathway for delivery of care for
    back pain
  • New reimbursement strategy required to align
    incentives
  • Improved ways of working with PCPs, specialists
    and/or facilities
  • Documentation and publicity of initiative
    designed to assist in repeating new approach in
    other locations, with other provider
    organizations

32
Helping Plan Members Make the Change to
Consumerism
Consumer Decision- Support Tools
The right decision-support tools can help
consumers
  • Cost of care
  • Cost advantages of using network doctors and
    hospitals
  • Quality of care
  • Health information
  • Health risk assessment
  • Management of HRA, HSA or FSA dollars

33
Resources to Help Consumers Research Cost
Quality
  • Intuitive, easy navigation
  • Delivers what users want
  • Links to related information
  • Easy on the eye
  • Secure

Access to Online Tools 24/7
34
Estimate the Cost of Care
35
Estimate the Cost of Care Diseases and
Conditions
36
Informed Care Decisions Treatment Options
37
Price-A-DrugSM
  • Cost of medications based on the consumers
    pharmacy benefit plan
  • Retail mail-order, including mail-order
    savings
  • Generic/brand alternatives consumers can discuss
    with their doctor

Available only if enrolled in this benefit with
Aetna
38
Hospital Comparison Tool
  • Nationwide quality outcomes information on
    hospitals for certain diagnoses and procedures
  • Number of patients
  • Mortality rates
  • Complication rates
  • Length of stay
  • Links to Leapfrog Data

39
Consumers Give Feedback on Their Doctors
40
(No Transcript)
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