Managed Healthcare Executive - January 2009 - (Page 16)

NEW ERA OF COMPROMISE “We have become a society that never wants to compromise,” says SummaCare’s Hauser. “We’re all going to have to agree on what is meant by a basic bene t. We talk about xing the problem, but we don’t talk about the fundamentals of it and getting everybody to agree.” For example, Hauser believes that nearly every provider wants its own service or area of specialty to be considered an “essential” service so it will gain business from any new reform plan. He sites bariatric surgery and cosmetic surgery as examples of specialties that some could argue are essential to patients’ health. “There are a lot of things that do good for people but the question is, is it something a government or insurance plan or employer should pay for?” he says. He hopes Congress will pioneer a new era of compromise among healthcare stakeholders, including the government itself, for the sake of holding costs in check. Insurers back additional policy changes to make individual coverage less costly. Tax reforms, for example, could permit individuals to deduct the cost of health insurance and could provide refundable tax credits for those earning less than 400% of the federal poverty level. Another idea is to permit public programs, such as Medicaid and SCHIP, to “wrap around” private plans in order to provide premium assistance to those newly eligible for public plans who want to retain a commercial plan. Initiatives to streamline administration and facilitate communication among insurers, providers and patients further promise to reduce ine ciencies and waste. Health IT is intertwined with many of those e orts. Insurers seek a streamlined system for communicating patient eligibility, bene ts, coinsurance and plan limits to providers. Pilots in the works aim to establish a multi-payer online 16 JANUARY 2009 Prepare for possibilities New markets opened through the proposed insurance exchange Mergers and acquisitions among MCOs National reform that pre-empts state initiatives IT funding New enrollees Guaranteed issue and community rating Rate restrictions Medicare-like pay rates yielding higher charges to private plans Congressional vote on SCHIP in March Payment reductions for Medicare Advantage plans Source: PricewaterhouseCoopers’ Health Research Institute portal able to facilitate information exchange in real time, according to AHIP. QUALITY COLLABORATION Hauser remembers the days when banks managed credit-card transactions independently but later moved to the clearinghouse model to streamline the laborious and often redundant processes in simple nancial transactions. Today, a credit card from nearly any issuer can be used worldwide, and he believes healthcare organizations should adopt that collaborative model, too. “Why can’t the health industry, not just the insurance industry, but the health industry as a whole come to that kind of mindset?” he says. “The reason why the banks did it is because they gured out it makes more sense to compete on service, quality and attributes than on who can process the credit-card claim infrastructure better.” He says streamlining healthcare will require “a huge commitment,” and personal health records should be a priority. Insurers are working with providers to develop uniform methods for physicians to submit performance information. Instead of dozens of di erent performance measurement systems, a collaborative e ort aims to create standard metrics for measuring, reporting and evaluating quality information across all public and private providers and payers. A uniform template to measure provider performance would improve a system that is “very confusing and frustrating to providers,” says AHIP President Karen Ignagni. Standard data aggregation, moreover, would give providers and consumers more useful performance information. And better information on provider performance could support payment systems that reward excellence. Insurers have been implementing P4P for several years and want to extend these and other new payment models to the broader healthcare system. Carriers also are working with state agencies to establish online consumer information on all available plans and coverage options in a state. Many health plans are supporting community health programs, such as campaigns to reduce obesity and tobacco dependence. “The shift toward improving personal and population health as a core strategy to contain medical costs will fuel demand for a new generation of innovative, Internet-based technologies” says Dennis Schmuland, MD, Microsoft health plan industry solutions director and MHE editorial advisor. “These technologies will need to go where consumers go and make it easier and more natural for them to communicate with payers and doctors, share insights, work together and

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Managed Healthcare Executive - January 2009 Contents Editorial Advisors For Your Benefit News Analysis Politics & Policy Letter of the Law Managed Care Outlook New Day 5 New Realities of Disease Management Pharmacy Best Practices Health Management Technology State Report: Hawaii MHE Resource Ad/Edit Index

Managed Healthcare Executive - January 2009

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