The insurance coverage piece is kind of separate from the value piece because solving it primarily relies on government policies that subsidize the purchase of health insurance for those who wouldn’t be able to afford it otherwise. Those government policies are a (purposeful) distortion to the healthcare market. Distorting a market for a good reason is fine, but before you do it, you need to understand how the market should be structured to optimize value so you don’t accidentally ruin its potential to have higher value in the process.
Our healthcare system is currently in experimentation mode–we are trying thousands of experiments to figure out how providers can be rewarded for “value instead of volume.” All the new terminology and reimbursement ideas accompanying these reforms can be hard to keep straight if you’re not steeped in this stuff every day, but guess what? There aren’t actually that many different ideas being tried; there are just a bunch of the same ideas being tried in various combinations. First I’ll describe those four basic ideas, and then I’ll show how they are the building blocks of all the main payment reform experiments out there.
Quality bonus: Give a provider more money when he hits performance targets on whatever quality metrics are important to the payer.
Utilization bonus: Utilization metrics and quality metrics are not usually separated, but they should be. Here’s the difference: improved performance on a quality metric increases spending; improved performance on a utilization metric decreases spending. They both improve quality, but they have different effects on total healthcare spending. So, for example, ED utilization rates and readmission rates would be considered utilization metrics. And childhood immunization rates and smoking cessation rates would also be considered utilization metrics because they tend to be cost saving. Insurers love giving providers bonuses on utilization metrics because they are stimulating providers to lower the amount being spent on healthcare.
Shared savings: If a provider can decrease spending for an episode of care (which could be defined as narrowly as all the care involved in performing a single surgery or as broadly as all the care a person needs for an entire year of chronic disease management), the insurer will share some of those savings with him.
Capitation: The amount a provider gets paid is prospectively determined and will not change regardless of how much or how little care that patient ends up receiving. Again, this could be defined narrowly, such as all the care involved in performing a single surgery (in which case it’s actually called a “bundled payment”), or it could be defined broadly, such as for all the care a person needs for an entire year.
By the way, did you notice that shared savings and capitation are almost the same thing? The only difference is who bears how much risk. In shared savings, the risk is shared, which means that if the costs of care come in lower than expected, the insurer gets some of the savings and the provider gets some of the savings. In capitation, the provider bears all the risk, which means that if the costs of care come in lower than expected, the provider gets all of the savings.
Okay, now that I have listed out those four ideas, take a look at the popular payment reforms of the day . . .
Give a primary-care provider a per member per month “care management fee” (in addition to what he normally gets paid) for providing additional services (such as care coordination with specialists, after-hours access to care, care management plans for complex patients, and more)
Also give the primary-care provider bonuses when he meets cost and/or quality targets
Breaking down a medical home:
A care management fee is actually a utilization bonus (because the net effect of the provider offering all those services is to avoid a lot of care down the road)
A bonus for meeting quality targets is either a quality bonus or a utilization bonus depending on the specific metrics used
A bonus for meeting cost targets is shared savings
Accountable Care Organization (ACO)
Give a group of providers bonuses when they lower the total cost of care of their patients (but the bonuses are contingent upon meeting quality targets).
Breaking down an ACO:
A bonus for lowering the total cost of care is shared savings
When a bonus is contingent upon meeting quality targets, that means it’s also a quality or utilization bonus (depending on the specific quality metrics used)
Pay for Performance (P4P)
Give a provider bonuses when she meets quality targets.
Breaking down P4P:
This is either a quality or utilization bonus (depending on the specific quality metrics used), but it tends to be utilization bonuses because insurers especially like when providers decrease the amount of money they have to fork out
Bundled Payment/Episode-of-care Payment
Give a group of providers a single payment for an episode of care regardless of the services provided.
Breaking down bundled payment:
A bundled payment is a narrow form of capitation
There you have it. They are all repetitions of the same ideas but combined in different ways.
In my previous post, I described the three ways prices can be set in healthcare: administrative pricing, bargaining power-based pricing, and competitive pricing. I also bemoaned the fact that the prices paid to providers by private insurers are determined more by relative market share than by anything else* . . . but this post explains how we can change all that.
I see two possible pathways from bargaining power-based pricing to competitive pricing, so here they are.
Let’s pretend a colonoscopy clinic is super innovative in how they do things, and they eventually are able to lower their costs by 20%. This is great for them because the prices they are paid by insurers has stayed the same (remember, those prices are determined primarily by relative market share, not costs), so now they have a really solid profit margin. And yet, the managers of this clinic still aren’t satisfied because they have excess capacity they want to fill.
One day, the managers come up with an idea. They say, “Up to this point, we’ve always maximally leveraged our bargaining power with insurers to win the highest prices we possibly can, but what if we do something radically different? What if we offer to lower our prices by 10% in exchange for the insurers putting us in a new, lower-copay tier? This would induce way more of their policy holders to choose us for their colonoscopies, so we’ll fill up our excess capacity. And, according to our calculations, our increased volume will more than make up for the lower prices. So everyone wins! Our profit increases, the insurer saves money with the lowered prices, and the patients are happy because their copays are less as well.”
Soon, some of the clinic’s competitors would figure out why their volume is starting to drop, so they would probably find a way to offer lower prices to get put into that lower-copay tier as well. Competitors who can’t or won’t lower prices will slowly lose market share until they, too, are forced to either lower price or improve quality enough to convince patients that going to them is worth the extra money.
Voila! Competitive pricing.
I have a friend who manages a large self-insured employer’s insurance plan, and I asked him what he would do if a clinic came to him offering lower prices in exchange for steering more employees to it. He said as long as the provider can show that quality won’t go down with the additional volume and that wait times for appointments won’t increase, he’d probably go for it.
Now, of course this wouldn’t work with every kind of healthcare service. I purposely chose a non-emergency service that already has pretty straightforward pricing. But as a priori quality and pricing information becomes more available, more services will be candidates for this pathway to competitive pricing.
One other point: Hospitals generally do a horrible job of cost accounting (they’re just such complex organizations!), so they usually have no idea if a proposed price reduction will still be profitable or not. Thus, they’ll be left behind in this game until they start to develop better cost accounting methods. If they have some foresight, they’ll start fixing that now.
An insurer is despairing the fact that many of the providers in the region have combined into a single price-negotiating group, so now the insurer is stuck paying way higher prices than before. But then some health policy-savvy managers figure out a solution. They say, “Let’s implement reference pricing for a bunch of non-emergency, straightforward services. Let’s start with colonoscopies. This is how it works. We’ll tell our policy holders that we’ll put $1,200 toward a colonoscopy (the “reference price”). If a policy holder chooses a provider who charges more than that, they will pay everything over that price. A few clinics in the area offer prices that are lower than $1,200, so policy holders will still have a few options if they don’t want to pay a dime. But, (and here’s the best part) the price the providers in that huge price-negotiating group forced us to accept is $3,000, so they’re definitely going to lose a lot of volume, which will probably force them to lower their price.”
In conclusion, shifting to competitive pricing is not immediately possible with most healthcare services. But the way to make more healthcare services amenable to competitive pricing is to improve a priori quality and pricing information: quality information needs to be standardized and more relevant to the factors patients should be considering when they’re choosing between providers, and the full price of an episode of care needs to be available beforehand so patients can compare them apples to apples. Only after these changes happen will we be able to rely more on competitive pricing, which, most importantly, will do more to stimulate value-improving innovations in our healthcare system than almost anything else.
* I also complained about how administrative prices don’t encourage (and actually stifle) innovation toward higher quality and lower prices. Check out the Uwe Reinhardt quote in this blog post and then think, “Uwe must have been reading Taylor’s blog.”
A good friend just told me about Montana’s state-run clinics that are only for state employees. Going to the clinic is free for state employees, which means the state is paying for everything. And yet, despite paying for everything, the clinics are doing such a good job of managing diseases that the state is actually saving more money than it’s spending on the clinics.
I’ve talked about the importance of cost-saving prevention before, but my point in describing this example is to illustrate a growing trend in healthcare–a trend that is largely unrecognized, but is starting to fix healthcare. So let’s break it down.
Think of the Montana state government as a company. This company, just like most companies, has suppliers that sell it critical inputs it needs to perform its services. And one of the most important suppliers to this company isn’t obvious: healthcare providers. Think about it–they are supplying the healthcare that keeps employees productive, which is surely a critical input.
And here’s the interesting thing about the relationships companies have with their suppliers: if the supplier’s product is too expensive, or isn’t good enough in some way, companies will sometimes just take over the production of that critical input themselves. This is called “backward integration.” Think of all the ways employers are backward integrating into healthcare, whether it’s having their own salaried physicians or working closely with providers to redesign care processes; they’re all variations on the same theme.
But employers aren’t the only ones with a supplier-buyer relationship with healthcare providers. Insurers depend on providers to supply the healthcare they are guaranteeing to their customers. So are insurers backward integrating as well? YES. Any time an insurer joins up with a provider, it could be seen as an attempt by insurers to backward integrate (ahem, ACOs). And insurers are also going crazy trying all sorts of hands-off approaches to backward integration (if it’s hands-off, can it still be called backward integration?) with things like pay for performance, bonuses for starting medical homes, and probably hundreds of other experiments I’ve never heard of. They are all attempts to exert some degree of control over the unsatisfactory supplier. Or, in other words, to fix healthcare delivery.
So, I guess we could say that employers and insurers are fixing healthcare delivery. Strange, isn’t it?
[Update: This is good and all, but there are only so many innovative things a single provider can develop, which is why an even better (system-wide) solution would be to do the following: get patients to choose the highest-value providers, which then rewards those highest-value providers with market share, which creates an incentive for all providers to be innovating to win more patients. This idea is expounded more in other posts on this blog. Anyway, in the meantime, this backward integration thing is a great alternative.]
At the recent AcademyHealth Annual Research Meeting in Baltimore, I went to a session on the accomplishments and challenges of community collaboratives. A community collaborative is a pretty cool idea that goes something like this: for a specific community (i.e., city), let’s get all the leaders of the providers and payers in a room (plus a bunch of other stakeholders committed to improving health) and make some decisions collaboratively on how we can fix healthcare in the community. The Robert Wood Johnson Foundation has provided the money to make these things happen in 20 different communities in the U.S. (see Aligning Forces for Quality, and Value-Based Payment Reform).
Sounds like a great idea, right? Well, an interesting challenge has arisen. More and more, these collaboratives are expected to find ways to reduce the total healthcare spending in that community. But so far, they’ve pretty much failed miserably. Why? Well, think about it. Here are all the leaders of payers and providers in that community sitting in a room together saying, “We need to reduce total spending,” but the savings are going to have to come from someone in that room, and none of them are going to say, “Sure, my organization will take one for the team! I’ll have to cut everyone’s pay, but because it’s for a good cause, they’ll love it.”
Does this mean these kinds of collaboratives are utterly useless in terms of lowering total spending in communities? That was the question I (carefully) asked at the end of the session, and one of the panelists gave a really insightful answer. To paraphrase/translate/elaborate on what he said, his answer went something like this:
Yeah, we’re not going to convince anyone in that room to just give up money like that. But what we can do is come up with standardized ways of reporting prices and quality. And when those are standardized across all payers and providers, patients will be better equipped to choose higher-value payers/providers, which, in the U.S., usually means ‘cheaper’ payers/providers. So this standardization will allow total spending to go down by getting more people receiving services from cheaper competitors. Thus, the higher-priced competitors will be the ones who are losing money when total spending goes down, all because we helped standardize quality and price reporting.
I agree. There are still many barriers to getting patients to choose these “higher-value” providers/payers, but this would help solve one of the biggest ones. And with each barrier we overcome, more patients will be enabled to receive higher-value care, which is what everyone wants, right?
The Bitter Pill article has received a lot of press lately. People reading it have often turned to a simple solution: regulate prices. The most straightforward approach to this is called “all-payer rate setting,” which has been experimented with before in some places in the U.S. and is still used in Maryland. The basic idea is that the government says, “When any provider performs this certain service, he/she will be paid this much for it no matter who the payer is.” And they set prices for every single service. Think of how this would instantly make all chargemasters a thing of the past. And no more worrying about hospitals increasing their bargaining power as they join together to form ACOs. And all that administrative complexity that would be gone (thus decreasing costs a fair amount)!
But there are downsides, too, which are not as obvious and may lead people to jump on the bandwagon of all-payer rate setting ignorantly. First, back to basics:
Total spending on healthcare = price * quantity
Yes, we probably have some quantity problems (running too many scans, etc., which regional variation literature attests to quite thoroughly), but the main reason we spend so much more than other countries is because of the prices. So, here’s the prices equation:
Price = Cost + Profit
What’s making prices too high? Brill makes a strong case that, at least in a lot of hospitals, profit is part of the problem [Update: Turns out most hospitals lose money on average, so it’s not as big of a deal as we thought]. But what about costs? Is the actual cost of care too high as well? YES, costs are the major problem, as shown by looking at the average profitability of healthcare organizations. More evidence of this: even in countries that do a pretty good job minimizing unnecessary services and regulating profits to reasonable levels, healthcare spending growth is still unsustainable, which only leaves cost as the primary culprit. Therefore, any policy (whether it’s meant to regulate profits, improve access, improve quality, or whatever) that creates barriers to cost lowering should be reserved as a last resort.
So, would all-payer rate setting create a barrier to cost lowering? If yes, I don’t like it. If no, let’s consider it.
First, since I’m reading The Wealth of Nations lately, let’s ask Adam Smith what he thinks about the subject:
I shall conclude this long chapter with observing, that though anciently it was usual to rate wages, first by general laws extending over the whole kingdom, and afterwards by particular orders of the justices of peace in every particular county, both these practices have now gone entirely into disuse.
By the experience of above four hundred years [says Doctor Burn] it seems time to lay aside all endeavours to bring under strict regulations, what in its own nature seems incapable of minute limitation: for if all persons in the same kind of work were to receive equal wages, there would be no emulation, and no room left for industry or ingenuity.
Particular acts of parliament, however, still attempt sometimes to regulate wages in particular trades and in particular places. (Emphasis added)
What’s he trying to say? All-payer rate setting would leave “no room left for [cost-lowering] industry and ingenuity”? (If you’d like to see my explanation for why I assume innovations by providers are generally cost-lowering, see here.)
I’ve explained before how taking away the freedom to set your own prices also removes much of the rewards for cost-lowering industry and ingenuity. In short (and simplified), lowering costs without sacrificing quality means you can lower prices more than others and therefore offer higher value than others, and higher value will eventually be rewarded with market share and profits. (Another assumption I’m making: patients preferentially choose higher-value providers, which is starting to be more true, but there are still many barriers to it.)
Back to the big picture: All-payer rate setting reduces the potential rewards for cost-lowering innovations, which I can guarantee will reduce the amount of cost-lowering innovation that goes on. So, yes, all-payer rate setting will be a barrier to cost-lowering innovation. And that’s a huge problem, so let’s look for other ways to fix egregious profits and costs. More to come . . .
When someone is arguing that the health system needs an overhaul, one of the most common reasons they cite is that “our health system is built on a flawed foundation of fee for service.” Arguments like this always sound so bulletproof when they rely on vague yet widely accepted assumptions, but let’s think clearly about this, just for a moment.
First, let’s go back to Econ 101 to recall that association does not imply causation. So, when you see a health system based on fee for service that is delivering surprisingly low value, you are seeing an association. It starts to look a lot more like causation when you compare this health system to other health systems in the world that are not built on fee for service but are all delivering much higher value. But it starts to look a lot less like causation when you compare this health system to any other industry and see that nearly all of them are based on fee for service yet somehow delivering excellent value. (I’ll come back to this later.)
So what is fee-for-service reimbursement, really? It is simply one extreme end of a spectrum, and at the other end sits capitation:
This spectrum is not well understood. People always think of it in terms of incentives (“bad” incentives at the fee-for-service end, “good” incentives at the capitation end), but what is actually being varied as you move from one end to the other? I’ve never heard anyone talk about that. So let’s talk about it; the conclusion will be surprising.
I will say that fee for service is the purchase of a narrowly defined service (e.g., a single doctor visit, a single operation, a single medication), whereas capitation is the purchase of a broadly defined service (e.g., all health care you need for a year). So, breadth of service purchased at one time is really what varies on this spectrum. But in addition to the breadth of the service being purchased, there is another important difference: risk. When you pay for narrowly defined services one at a time, you have all the risk (meaning, if you get sick or break your arm, you’re the one who is financially accountable). And when you pay for a broadly defined service, the party you’ve paid has all the risk (meaning, if you get sick or break your arm, they’re the one that is financially accountable). Note that this is primarily where the “accountable” comes from in accountable care organizations–they have the financial risk, not the patient.
This is a spectrum because a service could sit at any point along it. For example, Qliance offers flat-rate, no-limit primary care; they are financially accountable for anything that could be considered primary care. Another example is episode-based billing, where the patient pays a single lump sum in exchange for a guarantee that the provider will do everything necessary to treat the specified medical condition. An interesting side note is that even a typical fee-for-service doctor visit is not truly fee for service in the sense that the patient has all the risk; at least, last time I checked doctors don’t make patient pay larger copays any time appointments run longer than the allotted 15 minutes.
So what can we conclude from this discussion? Is fee for service actually bad?
Being too far at the fee-for-service end of the spectrum can definitely be bad if it means patients are expected to coordinate complex care by themselves. But being too far at the capitation end of the spectrum can also be bad if it means patients are not at all financially responsible for the services they choose to consume and are also stuck having to get all their care from one source that will inevitably provide less-than-exceptional quality for some services.
This means we need to find the perfect point somewhere in between the extreme ends of the spectrum where our health system will deliver optimal value. This point obviously depends on the service and the individual involved, as well as who can bear risk most effectively, but the way to think about it is using the “jobs” principle as taught by Clay Christensen. When a person enters the health system, it’s because they have a “job” they want to get done. That job generally isn’t something as narrow as to get an x-ray; more likely, their job would be to fix a suspected broken arm, so they’re looking to purchase all the services together that can fulfill that job. The job could also be broader, like to have the peace of mind that they have little to no healthcare-related financial risk and can just go and get care from one source no matter what comes up, or also to have help to keep healthy and thereby reduce care-requiring episodes (think: Kaiser Permanente and similar integrated delivery systems).
If we want to successfully redesign our healthcare delivery system (isn’t that all the talk these days?), we need to understand that fee-for-service isn’t intrinsically bad; the only bad thing is missing the sweet spots on that spectrum.
One final, crucial point: Yes, overhaulists* properly attribute many of the problems in our system to it sitting too far at the fee-for-service end of the spectrum (e.g., overtesting, overtreating, fragmentation), but they have overlooked what has caused the system to fail to adjust itself to a more optimal, jobs-focused point on the spectrum, as other industries do. This has everything to do with value not being financially rewarded in our system, and it is the topic of the publication I’ve been working on, as well as many future blog posts that will start to lay out the solutions more cohesively (after my publication comes out). More to come!
* My term for someone who believes the entire health system needs to be overhauled