Alliance bases incentives on health, not savings
Employers bet quality will win out
Unhappy with their managed health care programs, a coalition of Ohio employers are betting that by concentrating on quality preventive care instead of short-term cost control, they can better contain their employee medical expenses over the long term.
Many managed care plans are now demanding — and receiving — premium hikes in the 10%-12% range. Prompted by a combination of skyrocketing prices and employee preference, more firms are dropping the old HMO in favor of a physician-led health product such as a preferred provider organization.
"Right now, the HMO idea is just not selling, " says Bob Pures, senior vice president at Horizon Blue Cross & Blue Shield of New Jersey.
The Tri-River Valley Healthcare Initiative, an alliance of major, self-insured employers in the Dayton area, has taken this trend one step further by creating its own physician-driven managed care alternative.
Unlike the typical HMO, the alliance gives physicians the first and final authority over what they feel is the best treatment for a particular patient. Another major difference is that instead of basing financial incentives on how much less money they spend to treat patients, the alliance bases incentives for participating doctors on how healthy they’re able to keep employees.
Conflicting financial interests
The incentives that typically drive the financial and patient care portions of most managed care plans often work at cross purposes, maintains John Tonkin, executive director of the Tri-River Healthcare Initiative.
When that happens, it can create a dynamic that forces employers, insurers, and health care providers into an almost adversarial situation to protect their financial interests, while what is best for the patient can get lost in the process.
In an effort to break this cycle, the coalition has made a bold bet that putting physicians back in control of health care decision making, combined with an emphasis on preventive care and consumer satisfaction, will produce lower medical bills over the long term.
Since preventive care is the focal point of the program, physicians’ financial packages are geared towards diagnosing and resolving potential medical problems early on.
Bottom line: The healthier employees are, the less these companies will have to spend on medical benefits — leaving more money on the table for their docs to pocket.
As part of this approach, an Internet-based system is being put in place making it easy for patients to e-mail health-related questions to their doctors while also giving them fast access to medical information on the Web.
Another major change is that instead of acting as a gatekeeper who tells participating doctors what they can or cannot do, the Tri-Cities insurance plan’s main function will be to collect and share information providers can use to improve the quality of their care.
Like a traditional managed care plan, employees can pick their primary care providers from the list of participating physicians — or opt to use an out-of-network physician, if their employer offers this alternative. Should a claim be denied, patients can appeal the decision to a panel of outside doctors for review.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content