Regional Insights: 'In-network' now key to health plan choice

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It's the time of year when many people must choose a health insurance plan. Although the national news has focused on the problems people are having in signing up for coverage through the new federal health insurance exchange, thousands of senior citizens are also facing choices about whether to get their health coverage through the traditional Medicare program or one of many different Medicare Advantage insurance plans, and many workers with employer-sponsored insurance will have new choices to make during their open enrollment period.

For the first time, many Pittsburghers are being forced to evaluate different health plans based on which physicians and hospitals are "in-network." Although the cause in our region has been the battle between UPMC and Highmark, employers and health insurance companies in other parts of the country are also increasingly offering "narrow network" health plans in an effort to reduce premiums.

The dictionary defines a "network" as a "group or system of interconnected people or things." Traditionally, most health plan networks haven't really been coordinated systems, but merely lists of physicians and hospitals that have agreed to give a bigger discount to the health plan. However, research shows that patients can stay healthier and get better quality care at a lower cost if the patients use a true network of high-quality physicians who work together in a coordinated way to deliver better outcomes.

What does such a "high-value" network look like?

The most important elements of a good network aren't the hospitals, because the network's first goal should be to help you stay well so you don't need a hospital at all.

Instead, the most important component of a network is an adequate number of high-quality primary care practices. A truly high-quality primary care practice does four key things for you: (1) It helps you get the preventive care you need to stay as healthy as possible; (2) it accurately diagnoses new health problems you experience and then provides or arranges for the most appropriate treatment in a timely fashion; (3) if you have a chronic disease such as asthma, diabetes, emphysema, or heart disease, it helps you manage that chronic condition successfully so you don't have problems and end up in the hospital; and (4) if you need specialists, the practice helps you find the right specialists and makes sure all of your care is coordinated.

Unfortunately, most people don't get truly high-quality primary care in any network today. It's not because the primary care physicians are bad, it's because of the way the physicians are paid by the health plan. For example:

* If you're frustrated by how little time your primary care physician spends with you during a visit, blame your health insurance, not the doctor. Medicare and most health plans pay doctors on the assumption that a typical office visit will last only 15 minutes. Moreover, doctors get paid less if they address multiple issues in the same visit than if they bring you back multiple times, even though it would save you time and money to get everything done in one visit.

* If you're angry because your doctor spends more time during your short visit typing on the computer than listening to you, blame your health insurance. Medicare and many health plans now reduce physicians' pay if they don't enter detailed data about you in an electronic health record.

* If you have trouble getting your primary care physician to answer the phone or respond to an email when you have a question or health problem, don't blame the doctor, blame your health insurance. Medicare and most health plans won't pay doctors for phone calls or emails with patients, they only pay for office visits. The more time a doctor spends on the phone, the less time he or she has to see patients in the office, but the only way anybody in the physician practice can get paid is if the doctor (or a nurse practitioner or physician assistant) sees enough patients in the office every day.

Some health plans are beginning to change the way they pay primary care physicians so the physicians can better customize care to what their patients really need. These "patient-centered medical home" programs are a step in the right direction, but most have been too small to make a significant difference.

That's starting to change, but not nearly fast enough. Fewer doctors are going into primary care because of their frustrations with the way they're paid, so it's going to be harder for people to find good primary care physicians if health plans don't start paying primary care physicians in better ways.

From time to time, you'll have a health problem that requires help from a specialist. But which of the dozens of subspecialties is the right one? If you need multiple specialists, will they all coordinate what they do so you don't receive conflicting medications or duplicative tests?

In a true "network," your primary care physician would help you find the right specialists and work with them to ensure all of your care is coordinated. But once again, the way doctors are paid gets in the way.

For example, in many cases, the specialist could advise you and your primary care physician over the phone about what to do, rather than making you wait for weeks or months until you can get an appointment to see the specialist in person.

But Medicare and most health plans don't pay specialists for giving advice over the telephone or by email, they only pay for office visits and procedures. As a result, many specialists can't see new patients quickly because their calendars are filled with office visits from patients they don't really need to see in person. Specialists also don't get paid for time they spend talking with other specialists or with primary care physicians to coordinate care, so it's no wonder that patients can find themselves falling between the cracks.

Some health plans are beginning to pay differently for the specialists in the "medical neighborhood" as well as for the primary care "medical home." In one pilot project, paying for email consultations with specialists resulted in dramatic reductions in the delays that seriously ill patients experienced in getting appointments with specialists, because the specialists were able to successfully address other patients' problems quickly through an email exchange with their primary care physician.

If you do need hospital care, you obviously want to make sure there are high-quality hospitals in your health plan's network that can take care of you. Unfortunately, the hospitals in our region don't publish information about the quality of the care they provide, so it's impossible to know whether one network's hospitals are better than another's.

Although you hear a lot of advertising about how certain hospitals are the "best" at one thing or another, most of those rankings aren't based on actual outcomes for specific procedures. The limited data available suggest that for common hospital procedures, most of the hospitals in the Pittsburgh region deliver care of similar quality, and many of the independent community hospitals do it at a much lower cost.

For more complex conditions, the best hospital for you may not be in the Pittsburgh region at all. Some national employers, such as Walmart and Lowes, are now paying not only medical costs but travel expenses so their employees can go to hospitals such as the Cleveland Clinic and Johns Hopkins that have committed to provide high-quality care at an affordable cost.

So before you decide which health plan to use, first choose a primary care practice that is committed to high-quality, patient-centered care. Ask the primary care physician which health plans pay to support high-quality care, and ask which plans pay specialists so they can work as a team with your primary care physician. If you choose a health plan that supports truly coordinated, high-quality primary and specialty care, you'll be healthier, you'll spend less, and you may never need to worry about which hospitals are in the network.

Harold D. Miller is president of Future Strategies LLC and adjunct professor of public policy and management at Carnegie Mellon University. He also serves as president and CEO of the national Center for Healthcare Quality and Payment Reform (www.chqpr.org).


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