Originally published 12/23/10 on iPractice.
- The Department of Health and Human Services, in collaboration with the Institute of Medicine, recently launched the Community Health Data Initiative, which will release data on a variety of topics, including smoking and obesity rates, access to healthy food, utilization of medical services, and quality of hospital treatments. The purposes are to “raise awareness of community health performance, increase pressure on decision makers to improve performance, and help facilitate and inform action to improve performance.”
- The Meaningful Use Rules for Electronic Health Record technologies will incorporate quality measures developed by the National Quality Forum, and so physician data would be far more detailed. Even if these data are devoid of patient identifiers, physicians could easily be distinguished based on unique metrics if they were to become public.
- After a hiatus of more than a decade, medical management infrastructure is being aggressively rebuilt by virtually every major health plan to cope with the requirements of healthcare reform. Despite the plans’ continued gain using the old paradigm of fee-for-service without much oversight, more aggressive medical management approaches based on performance and value data will almost certainly become far more prominent going forward.
- Many commercial health plans now provide an up-to-date online resource for primary care physicians who rank specialist performance.
- A reduction in medical loss ratios (effective 2010). That is, the percentage of premiums spent on medical claims should be no lower than 85 percent for large groups and 80 percent for small groups. Functionally, this requires insurance companies to limit the portion of premium dedicated to administration.
- The establishment of cooperative (i.e., member-owned) health plans (effective July 1, 2013). These new structures — under the Consumer Operated and Oriented Plan (CO-OP) program — would be “owned” by their enrollees, which would give them ample reason to root out unnecessary costs. Even more important, existing insurance companies are prohibited from being involved with these health plans, which means that the legacy plans will suddenly have new market competitors.
- A slowing of system-wide cost growth (effective January 1, 2018). By 2018, an excise tax of 40 percent will be levied on the portion of a health plan premium greater than $10,200 for an individual and $27,500 for a family. While most discussions during reform focused on taxing excessively “rich” (or expensive) health plans, as a practical matter it now appears that these rules could apply to nearly all health plans. New data from the Kaiser Family Foundation/HRET 2010 Employer Health Benefits Annual Survey show that 2010 premium growth for family health plans slowed dramatically, rising only about 3 percent this year. If annual health plan cost increases remain at 8.2 percent until 2018, as they have for most of the past decade, then they'll avoid the Cadillac tax. But if they rise much at all beyond this, to 9.1 percent, they’ll trip the threshold and the tax penalties will be significant.
- “Am I practicing as efficiently and effectively as I could?”
- “Are some elements of my care — e.g., laboratory tests, advanced images — simply there to boost my income? Are others based on preferences rather than hard data?”
- “If my success was tied to ‘value’ targets, how would I fare?”
- “If my patients’ costs (e.g., severity-adjusted episodic costs) and outcomes (e.g., postsurgical readmission rates) were compared to those of other physicians within my specialty, locally and nationally, how would I rank?”
- Install a stent into a stable heart patient and the plan might reimburse you a fraction of what you’re used to.
- Get rewarded for addressing and eliminating patient care gaps — e.g., HbA1c’s for diabetics; Pap smears for women; PSAs for men. Leave gaps unaddressed, and you may be penalized.
- Self-referred advanced images are more likely to be scrutinized and severely discounted. (In June 2009, a Medicare Payment Advisory Commission (MedPAC) report to Congress found that, in 2005, “episodes with a self-referring physician are associated with greater imaging spending than episodes with no self-referring physician, controlling for differences in patient severity level, geographic market, and physician specialty.”)