Tuesday, April 19, 2016

Do Health Plans Provide Any Value? Of Course They Do!

Image via Insperity.com 
Today’s post on Forbes titled Health Plan Industry's Worst Nightmare: Employers Realizing They Are Actually The Insurance Company by serial entrepreneur, healthcare luminary, and social media blogger Dave Chase - and I lend that last ‘blogger’ label with the utmost respect – seemed like something I should read. After all, I’ve labored in the health plan, healthcare payer and risk-bearing provider space for over 20 years. But what really caught my eye was the byline “what do health plans do that couldn’t be done better by an algorithm?”

Dave asks himself four questions apparently intended to solidify his stance that health plans don’t provide any value. Yet even before Dave asks one of those four questions Dave states that “self-insuring and working with TPAs is appealing to many companies.“  This post of mine posits questions back to Dave on each of his four questions.

For the Record - ‘Quadruple Aim’

Do health plans improve the care team experience?
I ask: Are doctors the only members on the ‘health care team?’ How many of the ‘bureaucratic services’ that wear out doctors are due to federal and state regulations? Certainly self-insured plans can circumvent many of those regulations. But for how long?

Do health plans improve the patient experience?
I ask: Similar to ‘care team experience,’ how much of a patient’s experience do health plans have direct input on? I think it’s misleading and presumptuous to reference Net Promoter Scores (NPS) when the majority of healthcare consumers have little skin in the game, are generally perspicacious with little ability to choose based on cost and quality - until just recently, and aren’t the ones making people wait, oft times rushing a patient through an encounter and then leaving them on their own largely responsible for 'patient experience?'

Do health plans improve outcomes?
I ask: What’s your definition of an ‘outcome?' What does a provider do that serves as a means to measure a good outcome? Over the last 35+ years I've had quite a few experiences with providers who HAVE NOT provided 'good outcomes' - at least in terms of the value I received for the large amount I had to pay them. But I was still on the hook to pay them. How come?

Indeed, until recent years, I don’t think I’ve ever had much information, opportunity and/or support to be someone who could intelligently contribute to a Net Promoter Score. Not to sound 'elitist' but as a parent of four 'millennials' I feel I've had more than my fair share of opportunities. Is being 'called on the phone' by a health plan or a provider a good measure of value received. Indeed I don’t think I’ve ever been called by any of the ‘major service or product providers’ that are a significant part of my life:’ – utilities, banks, grocers, auto makers, mortgage companies, etc. – unless I owe them money. Is it fair to single out health plans? I don’t know much about NPS so maybe it is?

Do health plans lower costs?
I ask: Maybe health plans don’t lower costs but do health plans not limit costs? Do health plans not provide any 3rd party oversight of providers who might otherwise have their financial way with a patient? One of the commenters on Dave’s post (Richard R.) makes a good point about this particular question of Dave’s. It’d be good if Dave could provide me with any links to his claim about MLR’s of 25-33% - even 40% as claimed here; at least MLR’s of the behemoth health plans?

On This We Agree
I do agree with Dave that many services provided by health plans might could be commoditized by algorithms. I’m not sure that percentage is 50% but I do hope that other tangible and intangible services of value that can't reasonably be ‘algorithm-zed’ are somehow made more ‘scalable.’ 

Dave raises the value of healthcare pricing transparency. I wonder out loud which members of the healthcare constituency – patients, providers, employers and health plans/sponsors - are the ones who are promoting price transparency? I suspect very few provider organizations are doing this and the ones that are promoting price and quality transparency mostly fall within primary care and certain ‘well-bounded’ medical specialties largely insulated from fluctuations in work effort, practice expense and malpractice expense. Indeed: once ‘healthcare consumers’ have transparency into what is actually happening, it proves to be eye-opening.

Everyone Needs to Sharpen Their Aim
To be sure, ‘achievement of the ‘Quadruple Aim’ should be a target everyone involved with healthcare should aim and shoot for. Just don’t shoot the wrong target because it’s the easiest, most politically correct target. Dave responded with a ‘No’ and a “Resounding No’ to each of his four questions. To me, those questions warrant additional consideration beyond his simplistic responses.

We're All in This Together
One last comment: I too think (and hope and pray) that Millennials will help ‘clean up the mess in healthcare’ that Dave believes Boomers have created. My wife and me have made a fairly significant contribution to the Millennial population Dave has called out: two girls and two boys. Now get out and clean up that mess your Mom and Dad made kiddos!