By Edward F. Shay, Esq.
Consumer directed health plans (CDHPs) have arrived in the health benefits marketplace. Arguably, CDHPs will impact physicians and other health care providers to a degree not seen since the rise of managed care. CDPHs share common organizational structures. CDHPs rely upon consumer decision support tools, including extensive use of data comparing providers, to influence consumer relationships with providers. As consumer decision support tools proliferate, they will impact heavily upon the doctor-patient relationship.
CDHPs typically describe a benefit scheme with the following characteristics. First dollar coverage under a health benefits policy with generous benefits is replaced with a combination of a health savings account and a high-deductible catastrophic benefits policy, often geared to selected provider networks. The health savings account is akin to a medical IRA. It offers tax advantaged, self-managed funding for health care up to about $5,500 annually. Employers may fund the account fully or in combination with employees. Money that is not used in one year may be carried forward to another tax year. The premium difference between the high-deductible policy and a traditional first dollar policy could be substantial enough to cover the employer’s annual contribution. Year two of such coverage could require reduced funding for health savings accounts and further aggregate savings for participants.
Beyond the basic funding mechanisms of CDHPs, employers and health insurers offer a range of consumer decision support tools (CDSTs) intended to make consumers more effective purchasers of care and better stewards of their own health. Consumer decision support tools vary widely, and the following information resources are commonly made available to CDHP participants almost exclusively through web sites on the Internet. Often, employers make these sites readily available on information systems they maintain in the workplace and encourage employees to use the sites.
Typical CDST web sites provide consumers with access to information about diseases states, disease specific treatment options, and drug treatment regimens. For example, Informed Health Choices, LLC, is a CDST vendor that partners with the large Devon Health Network to make consumer information available to Devon’s subscribers. Informed Health Choices makes available nearly 200 reports on serious medical conditions and surgical procedures. Another major CDST vendor, WebMD, offers its “Conditions Centers”to provide online integrated approach to prevention and treatment of more than 35 medical conditions.” Other health plans and CDST vendors offer comparable arrays of pre-packaged clinical information to consumers on drug choices and treatment alternatives. If direct to consumer advertising changed the dialogue in the doctor patient relationship with respect to drugs, CDST promises a proportionally more dramatic change driven by consumers armed with pages of downloaded printouts on diabetes, bypass surgery and other conditions.
CDSTs also include benefit management tools that allow consumer users to build their own health services diaries, manage their benefits and track deductibles. Health plans and CDST vendors offer web based enrollment in different health plans, and online tools to compare side by side various benefit designs. These tools enable employees to alter copayment amounts, manage eligibility online, check the status of a claim and conduct related health benefit administrative tasks.
Importantly, CDSTs widely include tools to enable consumers to compare health care provider based on purported measures of quality and cost comparisons. Some provider selection tools designate those providers who are endorsed by the health plan or selected for the most favorable utilization, deductible and cost sharing arrangements. Major CDST vendors with this capability include Subimo, LLC, Informed Health Choices, LLC, and HealthGrades, Inc.
CDSTs have focused heavily on comparisons of hospitals. Most vendors utilize publicly available Medicare comparisons and supplement those data with information available from state reporting agencies in over 20 states. Some CDST vendors use data collected by the Leapfrog Group that is based upon voluntary submissions by hospitals to the Leapfrog Group. Patient safety data is sometimes used also and may be based on patient safety indicators from the Agency for Healthcare Research and Quality. HealthGrades issues reports on year over year improvements in safety and quality by procedure. Using discharge data for over 100 hospital procedures, HealthGrades assigns between one and five stars (five the best) to give consumers a simple and accessible method to rate a hospital. Other vendors report outcomes by procedures. Among insurers in the Philadelphia area, Aetna offers these provider comparison capabilities as does United Healthcare. Independence Blue Cross recently partnered with HealthGrades to add that vendor’s capabilities to a CDHP web site that it calls ibxpress.com.
Both URAC and NCQA are now offering accreditation programs for online member communication, education and decision support programs. NCQA repots that 57 health plans have been evaluated and have passed its members connections accreditation program.
While much of the provider evaluation and rating process has focused on hospitals, CDST vendors are moving steadily forward with physician rating tools. At present, the challenge to developing valid and helpful tools for comparing physicians is limited available and meaningful data. HealthGrades, for example, profiles physicians based upon: (1) medical education, training and licensure; (2) board certification and specialty training; (3) foreign languages spoken; (4) gender; and (5) medical board sanctions reported. None of these data measure performance or outcomes, and basing quality and cost comparisons on these data would be misleading to consumers. Better measures need to be developed, and meaningful measures will require input and cooperation among the spectrum of stakeholders in health care. Because most of the necessary data is created by providers, comes from them, and will be used to fairly describe them, provider involvement is critical to the success of the development of decision support tools making provider comparisons.
Although CDSTs are still in their early stages of development, worrisome signs are emerging. First, the market demand for CDSTs is driven largely by the related problems of the cost of health benefits. In the competitive CDPH marketplace, health plans are moving unilaterally without consensus and participation with their provider partners. Sometimes this works and sometimes it does not. UnitedHealthcare’s United Performance Program illustrates the growing pains of CDSTs developed without participation by provider partners.
Beginning in the Spring of 2005, UnitedHealthcare developed and began to deploy across its Midwestern markets a program that rated physicians on the basis of cost and quality measures. Listed on employer or UnitedHealthcare web sites, the gold star physician program offered a provider selection tool to Midwestern consumers. Physicians that met pre-determined cost and quality standards were assigned a gold star and placed into a preferred network of providers from whom employees of large self funded health benefit plans could obtain care at preferred rates. However, in the St. Louis market, United stumbled over the fairness of standards and the effectiveness of the tools that it developed to award “stars” to physicians in its Performance Program.
To begin, United is reported to have based its analysis on two years of claims data for 2002 and 2003. Physicians who had not submitted a minimum of ten claims in the prior year were not eligible for a gold star no matter how stellar their performance might have been otherwise. Another limitation of United’s claims-based CDST was that claims data submitted by groups did not allow United to evaluate individuals within the group. Thus, all of the physicians in the prestigious medical group associated with the academic medical center at Barnes Jewish Hospital and Children’s Hospital in St. Louis got left out of the program. As a result, BJC Healthcare, the parent of Barnes-Jewish Hospital, threatened to terminate its relationship with UnitedHealthcare over the United Performance Program. Other St. Louis medical groups expressed comparable criticisms of the Untied Performance program. Faced with a public relations debacle for its touted CDST, UnitedHealthcare has moved carefully in recent months to partner with physician organization on the development of better performance measures for future CDSTs.
UnitedHealthcare’s mid-course correction with its United Performance Program should not lull physicians into a false sense of security about the future of CDSTs and consumer driven health plans. CDSTs will bring to medical practice a level of transparency that will be unprecedented. CDSTs are converging with other information trends in health care.
UnitedHealthcare was able to launch its Performance Program initiative in no small part because HIPAA has resulted in a huge growth electronic claims data upon which to base such programs. Other HIPAA developments will improve claims data based CDSTs. In the next year under HIPAA regulations, CMS will begin assignment of unique national provider identifiers (NPIs) and the use of NPIs in claims submissions. While group practices will continue to submit electronic claims for physicians in a medical group, the NPI will enable data miners to drill down and profile individual caregivers in a group. HIPAA’s forthcoming claims attachment standard will provide more and greater clinical data about physicians not now available in claims submission data. Further down the road, clinical data mined from electronic health records will provide comprehensive clinical data about physicians.
Consumer decision support tools are in their earliest stages and their continued proliferation is being driven by significant market forces at work in health care today. In five years, the roles of CDST in the doctor-patient relationship will be profound. Accurate and meaningful information will strengthen the doctor-patient relationship while misleading or inaccurate information may complicate that relationship considerably. Physicians and their societies need to act quickly to influence what standards, data and measures are used and push accrediting agencies to police CDST effectively.
Edward F. Shay, Esq., is a partner in the national health law practice at Post & Schell, P.C.