Health Reform Initiatives Underway But Challenges Await

by Mike Stock  on Monday, Sep. 10, 2012 12:00 am  

Mike StockPresident/CEO QualChoice of Arkansas

The Supreme Court’s affirmation of health care reform’s constitutionality will have profound implications for the health care industry. From doctors to individuals to businesses and employers — everyone can expect change.

One of the primary goals of this reform is to make health care accessible to more people. But, it is not enough to simply increase accessibility; it must also decrease costs. To accomplish this it is important to understand the dynamics of rising health care costs. Expanding coverage without addressing the rising costs will not cure our inefficient system regardless of who pays the bills — private insurers, government, employers or individuals. Most industry experts believe that to effectively reform health care, we must find ways to improve quality and get control of the broader causes of rising costs.

Private insurers, including QualChoice, have been advocates of meaningful change and better consumer engagement long before the Affordable Care Act was affirmed by the Supreme Court. Insurers have consistently worked alongside health care professionals and employers to explore innovative ways to improve Arkansans’ health, coverage and care. Some initiatives already in development by QualChoice and other insurance providers include:

Patient Education — It is imperative that consumers better understand their treatment options and the costs associated with those options. Every choice impacts medical care, cost and therefore premiums. It’s important that consumers make the connection between what they pay and what they get, so together we can change the system to deliver effective, affordable care for all.

Episode Payments — The payment model will move from the current fee for service model, which pays for activities, to an episode-based model focused on specific medical conditions and is designed to reward specific outcomes. At QualChoice, we are partnering with the Arkansas Department of Human Services Medicaid program and other private insurers to develop the Arkansas Health Care Payment Improvement Initiative. The objective of the initiative is to improve patient care while making the system more efficient and controlling skyrocketing costs through changing the provider payment model.

Patient Centered Medical Homes — Payers, like QualChoice, are working with physician practices to develop Patient Centered Medical Homes (PCMH). A PCMH is a transition away from a model of symptom- and illness-based care to a system of comprehensive, coordinated primary care for children, youth and adults. A PCMH model promotes active partnership with a personal primary care physician who leads a team of professionals dedicated to providing proactive, preventive and chronic care management through all stages of life. These personal physicians will be responsible for a patient’s coordination of care across all health care systems facilitated by registries, information technology, health information exchanges and other means to ensure patients receive care when and where they need it. The ultimate goal is to lower overall costs and improve the quality and efficiency of care these patients and their families receive.

Despite the numerous initiatives underway across the industry to rein in costs while improving access to quality care, the challenges of implementing health reform are significant. Most industry analysts believe that premiums will increase as a result of the legislative reform that guarantees richer benefits and limits the premium differentials allowed for individuals of varying ages. The law is designed for younger individuals to pay more and bring down the premium costs for older individuals. The belief is that insufficient discounts for the young and healthy may encourage many to drop coverage and pay the fine if it is less than the average policy costs. And premiums will likely continue to increase as new fees and taxes are phased in as mandated by the new law.

Arkansans deserve reform that controls escalating costs through balanced health insurance pools, health and wellness programs, disease prevention and chronic care management. Resources must be refocused toward systems that pay providers based on performance and their ability to keep patients healthy. It is also critical to increase consumer involvement in the decision-making process surrounding the management of their health care costs.

At QualChoice, we will continue to move forward with implementing reform requirements. And we will continue to support initiatives that ensure all Americans have access to quality, affordable health care and continuous health care coverage.



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