Don’t Get Too Distracted By the Smoke Coming Out of Washington

Health care has risen to the top of the national agenda and Washington policymakers are once again debating how to affordably provide coverage and care for Americans. It is a discussion we welcome. But in the meantime, let’s not lose sight of the fundamentals that will ultimately produce greater value for our health care dollars.

At the heart of a high-performing health system is quality outcomes. For consumers to make informed decisions, they’ll need more data—reliable, actionable data. Health plans operating in managed care are accustomed to demonstrating their value and in fact have performed well under such scrutiny.

The National Committee for Quality Assurance (NCQA), a national organization dedicated to measuring and improving health quality, has published annual evaluations of every private, Medicare and Medicaid health plan in the country for more than a decade.

The most recent health plan ratings released by NCQA last month show a strong connection between not-for-profit plans based in the community and high-quality, high-value care. It’s something that we at the Alliance of Community Health Plans (ACHP) and the Association for Community Affiliated Plans (ACAP) have long understood.

Looking only at plans that earned ratings of 4.5 or 5 out of 5 in NCQA’s ratings — about the top 10 percent of plans — a majority are our community-based, not-for-profit member plans.

  • 10 of 15 plans in Medicaid rated 4.5 or 5 were community-based, not-for-profit plans.
  • 26 of 58 commercial plans rated 4.5 or 5 were community-based, not-for-profit plans.
  • 14 of 32 Medicare plans rated 4.5 or 5 were community-based, not-for-profit plans.

Our organizations combine to represent a distinct minority of the hundreds of health insurance companies in the U.S. Why is there a concentration of high performance among not-for-profits?

Simply being not-for-profit allows plans to focus more on quality care and less on Wall Street. Without pressure to meet quarterly earnings targets, not-for-profit plans have more room to make long-term investments in quality improvement and members’ health. That’s one reason studies repeatedly find not-for-profit Medicaid health plans spend more of each premium dollar on medical care and less on administrative overhead (including shareholder dividends) than their for-profit counterparts.

Our member health plans have deep roots in the communities they serve, leading to connections with allied organizations, including groups that advocate for senior citizens, legal aid for low-income individuals, housing, nutrition, transportation and other community resources. 

An abiding commitment to the community means our plans stay put, whether times are good or bad. Community-based not-for-profits can’t and don’t migrate to other service areas in search of favorable market conditions. Instead, our plans compete on the basis of quality, service and wise use of resources, leading to innovation in areas ranging from technology to human services.

At Geisinger Health System, which serves consumers in Pennsylvania and New Jersey, online physician scheduling is available at several hospitals. The health plan’s members can use the service free of charge by downloading an app to their smartphone. Through the app, patients can locate providers, read reviews and set up appointments with primary care physicians and specialists. Geisinger has also begun providing refunds to dissatisfied customers, a program that has cost little and resulted in valuable feedback for constant improvement.

Several of our members are working to address social determinants of health. CareOregon knows access to housing is key to living a healthy life. The health plan has awarded more than $360,000 in grants to six organizations across the state of Oregon that work to keep vulnerable families in their homes. CareOregon staff selected the groups based on their ability to help members overcome barriers to both health care and stable housing.

Through a partnership with the local HUD authority, Community Health Services and Metro Family Practice, UPMC in Pittsburgh, Pennsylvania, developed the shelter plus care program to offer high-need members housing support and reduce hospital readmissions. Initially, the program included 22 members. Within the first year, 13 of the participating members experienced significant decreases in medical costs and remained in stable housing. UPMC plans to expand the program to include 50 members.

ACHP and ACAP members are uniquely positioned to deliver high-quality, high-value care. These not-for-profit plans’ focus on the communities they serve leads to innovative, tailored approaches to addressing the specific needs of the regions where they operate. It’s this approach that sets our members apart—and at the top of quality ratings.

Ceci Connolly is President and CEO of the Alliance of Community Health Plans, a coalition of nonprofit, regional plans serving nearly 19 million people.

Margaret A. Murray is CEO of the Association for Community Affiliated Plans, a group of 59 not-for-profit Safety Net Health Plans which collectively serve more than 17 million people through Medicaid, Medicare, CHIP and the Marketplaces.

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1 reply »

  1. Assuming that you have several plans that serve a Medicare Advantage plan, what do you know about their level of efficiency? Specifically, do you have any data, regarding their year by year hospital utilization as in days per 1000 members? Hopefully, it would be less than 3000 or is it considered proprietary information?