Standoff Between Continuum and UnitedHealthcare Over Costs - NYTimes.comA front in the national health care battle has opened in New York City, where a major hospital chain and one of the nation’s largest insurance companies are locked in a struggle over control of treatment and costs that could have broad ramifications for millions of people with private health insurance.
via www.nytimes.com
Call me perverse, but I'm somewhat jazzed by the dust-up between a major insurer and a major hospital system.
These two entities (in general, not these specific players) represent two of the major powers in health care backing the status quo.
Hospital systems want their beds full and to maximized 'bed-turns' (like turning a table over in a restaurant) since 'bed-turns' generate revenue. Some hospital systems work on quality but most assiduously ignore their primary care networks since robust primary care reduces the need for hospital beds.
Insurers manage actuarial risk and deal with the administrative burden of claims. They've been charging increased premiums for the added services of managing population health but their impact has been extremely limited and the results have not lead to any breakthroughs on quality & cost. They too have ignored robust primary care because it would compete with the plan-based population health management cash cow.
I freely admit that this is a somewhat simplistic and harsh assessment, but I have yet to see support for exemplary primary care from such players (ok, a few exceptions- I'll grant you Group Health in Seattle and a handful of others, but these are rare exceptions).
So I'm jazzed because this battle may signal a willingness to bust up the status quo - a willingness to at the very least support some meaningful pilots of exemplary primary care. I won't credit any of those anemic Patient-Centered Medical Home projects as true support.
Covering up to three conditions and a small handful of preventive measures and congratulating yourself for adopting some technology is so far from the goal that it's almost laughable (I would laugh if the amount of money and hyped expectations spent on such minor incremental change were not such a huge distraction from real improvement).
Exemplary primary care provides a foundation of excellence for all patients, not a subset with one of several conditions. Exemplary primary care doesn't credit "I bought some cool software and have a policy describing how we'll use it" but focuses on processes and outcomes that are meaningful to the population served:
- I can receive care when and how I need it
- I have a PCP who knows me as a person
- My PCP cares for the bulk of my health care needs
- My PCP coordinates any care I need in the health system
- I am much less likely to end up in the hospital or emergency room
- I am better able to avoid the risk of unnecessary procedures
So UnitedHealthCare - go for it. Dust it up. In the meantime if you want to take the high road I suggest you look beyond the typical status quo nonsense and partner with exemplary primary care. You want to really take on a hospital system? How about truly supporting a primary care network whose work will absolutely reduce the need for unnecessary high end specialist interventions and hospitalization.
The Ideal Medical Practices group and others know how to do this work and are as ever eager to engage. Support us so we can provide the care your members want and need. This will not only make you look good but will actually help your members get better care and outcomes.
Dr. Moore:
A little harsh, well perhaps....yet right on point to the nature of our dysfunctional health care non system. Follow the incentives and you will the find the encoded genotype for such selective 'non-engagement' of PCPs via an ideal medical practice concept. After all, absent a paradigm shift, why favor an organism, enterprise, or business model that directly threatens the very 'sick care' cash flows to which the 'health care bog' (aka conundrum) is so clearly addicted?
[NOTE: One amusing irony though, is at 17% of GDP, we often hear about a cash or capital starved pool of health care providers; I guess it's just not enough $$ (go figure).]
Though there are exceptions, particularly those clinically and economically integrated delivery systems who had the courage to retain vs. 'push back' risk so freely downloaded by health plans in the late 80s to late 90s, (and yes, they have problems too; not to mention bureaucratic complexity), including not just Group Health, but Kaiser, Geisinger, Mayo, etc., who value a preventive health care model.
Yet, I sense 'the times, they are a changin' (again); especially witnessing the grand failure of the legislative 'top down' vs. granular 'bottoms up manner' in which sustainable health care transformation is likely to be demonstrated.
Good piece, and thanks for the catch!
Posted by: Gregg Masters | January 25, 2010 at 11:22 AM