Why health plans remain leery of giving quality data to enrollees

February 21, 2020 11:08 pm
  • Available quality data still is unable to tell patients how individual clinicians rank in performing specific procedures.
  • Health plans worry a proposed federal rate-transparency requirement will sideline their more advanced initiatives.
  • Price transparency lessons learned by one plan included the need to provide specific patient costs instead of estimates.

Although health plans increasingly provide quality data to patients, some worry it is too vague and will be overwhelmed by price transparency initiatives.

Marti Lolli, senior vice president of consumer and government markets and chief marketing officer for Priority Health, a not-for-profit health plan with a 2% margin, said the plan’s key insights after studying transparency for years include:

  • Quality still is not among the top 10 factors driving patient care decisions.
  • Healthcare price and quality are inversely related.
  • Data on the most important point — procedure-level quality — does not exist.

Priority Health’s transparency tool for its enrollees provides quality data, including data from Healthgrades, HEDIS and the plan’s own database. Apples are used as icons to depict quality, and consumer reviews also are presented.

But facility-level data like the Centers for Medicare & Medicaid Services’ star ratings for hospitals, when paired with federal requirements that providers and plans reveal their privately negotiated rates, may drive patients to care that has little to do with the clinician performing a specific procedure on them, she said.

One quality proxy that could provide insight for patients is procedure volume information for individual clinicians, although that information also is unavailable, Lolli said.

Also addressing the issue at a recent healthcare policy forum in Washington, D.C., was Jason Mitchell, MD, chief medical officer and chief transformation officer with Presbyterian Health Services, who said quality data would be better used if shown to in-network hospitals, physicians and ambulatory surgical centers, with financial incentives tied to improvements in their results. The nine-hospital health system also operates several types of health plans, including Medicare Advantage plans.

Presbyterian tries to emphasize value — which includes cost and quality — while the health plans with which it negotiates generally only discuss unit cost, Mitchell said.

Presbyterian is educating patients about the risks of sharing their clinical data with the rapidly growing number of health application companies, Mitchell noted.

Concerns about the federal price transparency push

The Trump administration has finalized a requirement that hospitals post privately negotiated prices starting in January 2021 — although hospitals are challenging the rule in court — and has proposed a requirement for health plans to do the same.

Lolli said her concerns about the proposed health plan requirement include:

  • The information provided would be unhelpful to patients, who would need to sift “through 70,000 rows of data in an Excel spreadsheet on procedure codes.”
  • Health plans would have to shift resources away from their ongoing efforts to provide cost data tied to enrollee benefits.

“Don’t make us slow down to have to stand up a solution that’s not going to be helpful,” Lolli said.

Ceci Connelly, president and CEO of the Alliance of Community Health Plans, said the federal price transparency initiative also distracts from health plan efforts to engage with enrollees about care options that are available for various conditions.

Rural physicians may suffer under price transparency initiatives, Mitchell said, if their prices are shown to be high even though those prices are the result of higher costs in rural areas.

“Those are not the people you want to pressure. You’ve got to get those resources,” Mitchell said.

Lessons learned on price transparency

Lolli said Priority Health has learned a variety of lessons over the last 10 years about how to get price transparency data to enrollees. Those conclusions have led to a series of changes, including:

  • Replacing simplified “good or bad” ratings of provider cost with cost details
  • Replacing cost estimates with specific costs through real-time claims processing
  • Launching outreach to enrollees on appropriate care following any indication that they are seeking care
  • Dropping an initiative to inform enrollees after the fact about their overspending or lost rewards

Although the last initiative greatly increased price transparency tool use, it also “caused quite a bit of consternation,” Lolli said. “We decided that that might not be a right strategy for us to deploy.”

Instead, Priority is focusing on getting enrollees to use its price-shopping tool or to contact the health plan for help with shopping among providers.



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