Providers and insurers alike know that focusing on quality and cost will be essential, especially as healthcare shifts toward accountable care models. In fact, Greg Chittim, a senior healthcare IT consultant at Arcadia Healthcare Solutions, says the evolving healthcare landscape will drastically change the way that stakeholders negotiate managed care contracts
. In order to outpace competing health systems, providers must prove to payers that they can manage quality and cost more effectively than other practitioners.
“There is often a layer of distrust and/or misaligned interest between plans and providers. Often providers don’t trust plans with all their data, nor do they want to implement improvement programs for just that plan's members,” said Mr Chittim.
Challenges can arise, even when quality measures are determined from a source such as an electronic health record (HER). This is because not all data evaluation tools are created equally. To ensure that providers and payers are on the same page, Mr Chittim suggested that they use a third-party EHR vendor to ensure that fair quality measures are established.
“The innovative practices, and the ones that yield a contract the most attractive for both sides, are utilizing an impartial third party to gather some subset of EHR data and aggregate it into measures that can provide much better insight into quality and health,” Mr Chittim said. “This can be almost real-time data, and it provides a look at things that you can never get just from evaluating claims-things like weight and blood pressure.”
Determining how to reimburse quality may not be the only issue for providers in ACOs. A recent report suggests that patients’ indifference to healthcare costs can add to provider frustrations. Policy makers say that patients have little incentive to make a responsible choice when it comes to cost. Further research is required to understand exactly what changes are needed to satisfy both providers and payers, but also what will encourage patients to choose care options more wisely.
“We don't know how well they can steer or control care under the current constraints of the model,” said
J. Michael McWilliams, MD, PhD, associate professor of health policy at Harvard University.
Around the Web
Managed Care Contract Negotiations Morph Under PPACA [HealthLeaders Media]
ACO Efforts to Constrain Spending Face Hurdle—Patients [Modern Healthcare]