Since the enactment of both the Health Information Technology for Economic and Clinical Health Act (HITECH) and the Affordable Care Act (ACA), the healthcare industry has embarked on several initiatives to improve quality and lower healthcare spending. From the accountable care organization (ACO) and other payment model initiatives offered by the Centers for Medicare and Medicaid Services and the Center for Medicare and Medicaid Innovation to the high-deductible health plan initiatives undertaken by employers, to the trends in risk-based contracting by other commercial payors, the focus on quality and cost continues to be an important theme in healthcare. Access to timely, actionable data – especially with the widespread adoption of electronic medical records – renders the possibilities of success more attainable. At the center of all of this is the patient, who is now viewed as a customer and for whom engagement and satisfaction are of critical importance.
As more clients in our ERISA practice make the move to self-insured plans, and more clients in our healthcare practice seek innovative ways to attract and retain patients in this ever-competitive landscape, the trend towards direct to employer contracts continues. These types of arrangements can take various forms, from contracts for specific services at a fixed price, to shared savings/loss contracts, to cutting out the insurance company altogether by having the provider arrange for, or provide, traditional TPA services, employers and providers are collaborating in various ways to reduce healthcare costs and improve both quality and the patient experience. Once the parties move past the low-hanging fruit, i.e., high -risk, high-cost patients, reducing emergency department use, managing the drug formulary and utilizing step therapy, they can look at other drivers of cost within the reach of the parties to the contract (noting that prescription drugs, which are a cost driver, are not necessarily within the power of the provider to control). One such cost driver is waste, which includes things such as unnecessary services, inefficient delivery of care, inflated prices, and fraud. With patients sharing more of the financial burden, engaging them to be more proactive in their plan of care could include empowering them with the tools needed to better understand the care they receive.
Self-insured employers have a fiduciary obligation to ensure that plan assets are used for the exclusive benefit of participants and beneficiaries. Empowering their plan participants to not only take a more active role in their healthcare but to also understand the intricacies of the benefits they pay for may help in this regard. As we know, understanding an explanation of benefits can be daunting, but asking the right questions could mean identifying patterns that need to be corrected, such as unbundling items that should be bundled, or not billing with a correct place of service. Further, encouraging plan participants to discuss the cost of care and implementing decision support tools for the providers could reduce waste and save a lot of frustration, especially if the provider is in the role of a TPA and can have a consistent pricing menu for those self-insured plans that it shares with its providers. Finally, coding accuracy, while certainly an area of critical importance for Medicare Advantage plans, can be examined in the context of self-insured plans to spot trends and troubleshoot. Just as consumers are being encouraged to regularly check credit card statements, and customers regularly check grocery receipts and restaurant bills to ensure that they pay only for what they purchased and that the price is accurate, these employer-provider collaborations may unlock mechanisms for consumers to better understand what they are paying for and thereby reduce waste while improving the overall care experience.