Of all the provisions of the ACA, probably none has received greater attention from health insurers than the exchanges. Though the exchanges are expected to be the conduit for just a small fraction of all the insured at their start in 2014, they will be where most of the growth in health insurance lies. Given the rule that the individual exchanges must be integrated with Medicaid, their role will be critical for any insurer that wants to compete and grow in the individual or Medicaid markets. The dominance of the exchanges for growth in the small group and even the Medicare markets may not be not far behind. It should be no surprise if, eventually, all fully-insured business goes through the exchanges, leaving only self-insured plans outside.
So getting it right matters. Now is the time to think hard about getting it right, before the exchanges are created and inertia sets in. And, as some have argued, getting it right means that we think about the exchanges as places for people to choose their health care, not just their health insurance. So how should we do that?
Here is what we should not do: make it easy to choose care without considering both the quality and the cost of care delivered by the care system. It would be an enormous lost opportunity to improve consumer attitudes towards health care if we built the exchanges to make it easy for people to reason: “I like doctor A. Doctor A accepts insurance products X, Y and Z. Of these three, insurance product X seems to have the lowest cost, so I’ll choose product X.”
If someone is wedded to a particular physician for whatever reason, of course they should be able to do a search of insurance products that include that specific provider in their networks and choose insurance accordingly. However, the search tools in the exchanges should also be designed to prompt participants to learn about quality and how it relates to cost. And that can’t be fully done without including the larger clinical “system” in which the provider plays a part, which involves the care gap and care coordination support provided, and other factors like how much of the cost is paid out of pocket and, perhaps more in the future, the health insurance products that determine how and for what a provider gets paid.
This much is not controversial: If you have a primary care physician, the system of care starts with your physician. But it also includes the specialists to which the physician refers and hospitals to which the physician admits. That could easily turn out to be where your most critical care is delivered. The system could also include whether the Medical Home or Accountable Care Organization in which the physician practices. It would include the quality ratings for that provider, but also, ideally, quality ratings for the network of relations in which that provider practices.
Including all this in a search tool is easier said than done, of course, but since we’re thinking big, those building the exchanges should get clear about what the end goal really should be and start taking steps to get there. If someone first compares different insurance products by price and focuses on the cost and quality of insurance, the fact that we are really seeking access to quality health care can be obscured. But so can it be obscured if we take for granted that a person knows whether “their” providers are actually high performers. If we are going to build search mechanisms into the health insurance exchange that let them choose insurance based on provider, then we should also give people the information to judge when it is in their interest to switch providers. The exchanges should help deepen the patient’s approach to getting care.
The rewards for getting this right will only grow as information technology allows our health records to be shared across providers and systems. Continuity of care is important. Ideally, the physician entering the exam room already knows who you are and knows your history. But the unfortunate reality is that over half of Americans don’t have a primary care provider. Fortunately, it is also true that, as clinical information exchange accelerates, virtual continuity of care will become common. A lifelong medical record will come with the patient to every new physician office and be accessible just as readily to the new physician as to the previous one. Most of us will be seeing interconnected physicians within 5 years. A new physician could have the same or even better analytical tools to identify gaps in care than one’s old physician, with much less muss and fuss needed to figure it out than in the past.
For those managing a serious illness, real continuity of care will still be substantially better than virtual, other things being equal. But other things are not always equal, and for the majority of Americans virtual continuity will be far better than what they currently have, which is no continuity. As Americans grow to understand that, they will look less at individual physicians in isolation, give less weight to including a specific physician in the network, be less likely to assume they know the quality of a physician from how he or she makes them feel in the exam room, or what medical school they went to, and they will look more at interrelated systems of care.
And that brings us back to the idea of buying insurance. For most people, the best approach will continue to have three steps. 1. Filter down the insurance options to find benefit structures and premium levels you can accept. 2. Look for desired locally convenient and high quality providers who are in the networks for those products. 3. Consider the relative quality rating of the health plan on clinical measures and how well the plan serves the needs of its members.
Not all steps are of equal importance, of course. In the near term, the quality of the plan is mostly a product of network management and reflects the average quality of care in the region. But as plans experiment with smaller and more selective networks, improve their care management efforts and reimburse care by its value rather than volume or complexity, plan quality ratings are likely to become more significant.
There will be changes to step 1 as plans have more and better data to share on expected costs of care, but the more profound changes will occur around step 2. The long term goal is that when evaluating a physician one will not simply have access to a number, or some stars by the physician’s name for routine preventive metrics like breast cancer screenings and diabetes control, but information reflecting the physician’s mini-network within a network that impacts the care received.
Again, this is hard stuff, and while the exchanges can include some search tools from the beginning, some of this is years away and will require widespread use of interoperable electronic health records or multipayer claims data sets for the analysis. But the basic principles can be designed in to the exchanges now. Or, we can squander this unique opportunity to help people get a better view of what they want: cheaper, better access to high quality care.
Jonathan Halvorson, PhD, has worked for the past seven years in managed care for a regional non-profit insurer. His views are entirely his own and do not represent those of his employer or other known individuals, living or dead.