• Health care costs are crushing the economy, eating up state budgets, frustrating employers and causing consumers to make difficult kitchen table tradeoffs. In the past 50 years, health care expenditures have risen five times faster than the economy has grown.
• There is consensus finally that the rate of increase in health care costs and longstanding gaps in quality and safety cannot be sustained. Purchasers, consumers and government payers are rightfully demanding value for their health care investments and there are promising signs new solutions are working. While the challenges may be similar, the most promising innovations are fundamentally different than they were in years past.
• Across the continent, new payment models are being implemented. What’s different from the tools used in the ‘90s is that cost and quality goals are being set and health plans, hospitals, and clinicians are working together to align incentives to reward the provision of care that is high quality and cost effective.
• Health plans are working with primary care physicians to offer a ‘medical home’ to patients. The concept is to support physicians’ efforts to provide preventive care, coordination of care for multiple conditions, and services designed to maintain health and to coordinate care for those with chronic conditions. New accountable care models span a broad spectrum of care and involve health plans and providers working together to move away from paying for each service rendered toward financial arrangements that reward performance. A third approach involves health plans partnering with physician groups to pay for episodes of care, identify and promote best practices, reduce treatment variation, and provide better results and value to patients.
• What is strikingly different from past efforts is that these designs are emerging from partnerships among health plans, hospitals, and physicians that are working together to reform payment systems based on a shared recognition of the urgent need for practice transformation. Improved measurement toolsdeveloped by credible,objective third parties have enabled health plans and providers to agree on best practices and steps that will demonstrate tangible improvements. Goals now relate both to the quality and cost of care; neither are reviewed in isolation.
• The ability to set performance goals is supported by an enhanced ability to measure, collect, aggregate and analyze information on provider performance to pinpoint gaps in care and help drive quality improvement. Increasingly, health plans’ HIT infrastructure is enabling information exchange to support doctor and patient decision-making – in real time – thereby providing access to needed information at the point of care.
• Engagement in treatment choices helps patients make informed decisions and adhere to treatment plans and wellness programs designed for their specific conditions, such as heart disease, hypertension, obesity, asthma, and diabetes. Incentives can include waiving or reducing cost sharing for high-performing providers, particular settings of care (e.g., centers of excellence), or certain types of medical treatments, tests or screenings that have been proven to improve health outcomes.
• Transforming our health care system is not going to be easy, but it is necessary. We know what must be done to implement a sustainable, modernized health care system that engages patients and rewards value over volume.
• That’s our mission in the health plan community and that’s what our services and resources are designed to achieve.