Quality, With a Dash of Affordability

Healthcare is unlike any other business model that exists which is why it is difficult to manage and evaluate for innovation. To be sure, technology and “the man” are innovating but, it’s happening in a framework that is difficult to modify in short periods of time (generations). Regardless, the Medical Loss Ratio should not abdicate health insurance companies from providing quality and pricing transparency that patients can expect within their defined plans. This article will synthesize some of the tools you can work with as a consumer when you are evaluating the potential cost and quality of your healthcare providers. There are several organizations mentioned here that you can spend a great deal of time researching. For now, highlighting how these organizations provide some level of transparency into the black box of healthcare cost and quality is the focus.

The Leapfrog Group is a nonprofit watchdog that provides transparency around the quality outcomes patients can expect from healthcare systems. If a healthcare consumer has choices for their local or regional care, The Leapfrog Group provides a hospital compare tool that runs qualitative searches across a number of different metrics that Leapfrog Group captures in their annual survey’s. There are 10 sections spanning 28 specific measures that make-up these surveys. There are two main tenants that these surveys focus on:

  • Outcomes (readmission rates, infection rates, etc.)
  • Structural and process related measures (efforts towards creating safer care)

In 2018 there were more than 2,600 hundred hospitals that participated in this survey. Excluded from these surveys are DoD/VA hospitals, critical access hospitals, specialty hospitals, children’s hospitals, outpatient surgery centers, etc. The VA has their own quality reporting structure through the Strategic Analytics for Improvement and Learning (SAIL) Metrics and that is probably a topic for another conversation in the future. Leapfrog is a great resource for anyone looking to take a Consumer Reports type approach to their potential healthcare provider they are evaluating for their care.

Medicare.Gov is a site run by the Centers for Medicare and Medicaid (CMS) that houses everything you would ever want to know about CMS’ role within our healthcare system. Within CMS, the National Health Safety Network (NHSN) is a lesser known entity that requires hospitals to provide their Medicare infection data on annual basis. 1% of an eligible healthcare organizations Medicare reimbursement is dependent upon meeting a certain criteria of safety through the Hospital-Acquired Condition (HAC) Reduction Program. CMS reduces the reimbursement of a healthcare systems payments by 1% if they are in the bottom 25% of hospital acquired infection rates for Medicare patients. The NHSN provides the infection data they capture through a Hospital Compare Tool that healthcare consumers can use to evaluate their prospective healthcare providers outcomes data. While it’s not perfect, for my Atlanta natives try comparing the patient populations of a Grady Hospital to a WellStar Kennestone, it does provide some perspective on what sort of harm your prospective healthcare provider has caused previously. The data tends to show outcomes on a 15-month +/- trailing basis and is a good lagging indicator of quality.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is another lagging indicator type survey that provides consumers with content around the experience other patients had while in a particular facility. CMS developed this tool in conjunction with several other quality focused organizations to help set expectations with patients from the perspective of patient’s around the quality of the experience they can expect within a certain healthcare system. These surveys also drive reimbursement metrics through the Patient Experience of Care portion of the Value-Based Purchasing Program. There are 27 questions that patients fill-out after they are discharged to rate their experience within a particular facility. 10 Measures are currently reported at Medicare.Gov for this survey. A given healthcare system has to capture at least 300 surveys per reporting period in order to be considered compliant across the required reporting measures.

Clear Health Costs is a journalism-based organization from New York City that is creating true pricing transparency within states that tend to have more patient-friendly billing practices, for now. Here is a Ted Talk that CEO Jeanne Pinder gave on the topic and her role in developing the organization. Currently their reach is limited to select markets but it feels like they will continue to expand their reach, patients (a.k.a., people as Jeanne mentions) and providers alike are becoming more willing to share their experiences. This website relies on data and there is no better way to price out your potential healthcare expenses than through actual patient data. While exposing charge masters is a sign of the consumerization of healthcare, does anyone really pay MSRP of a car they are about to purchase? More importantly, given the complexities of providing care for populations, procedure and service-related expenses become even more fragmented when insurance is introduced. It’s important to know what your options are both with cash, hello health-savings accounts, and through your insurance plan.

The reality is at some point we all need to take advantage of our healthcare system for better or worse. Our healthcare system is Father time is after-all, undefeated! Why not act and prepare accordingly?

Published by Miers Q.

This website is a testament to the importance of our healthcare system and the importance our choices have on that system. I have worked in the health information technology software space since hanging up my baseball cleats. Hopefully this information can offer some unique perspective in a notoriously ambiguous industry.

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