Transparency in Health Care

I have worked in health care for over 30 years.  I have worked on the payer side, in medical group operations, and as a consultant for physician groups.  I have interacted with literally thousands of physicians over the last 30 years.  The most amazing thing about my career is that every single doctor I have ever worked with is the best in their field.  All of them provide the highest quality of care for their patients, and they are also cost-effective.  How do I know this?  Well, they all told me they are.   I have yet to interact with a doctor that will tell me, “I’m actually a mediocre doctor.  I graduated at the bottom of my class and, I order more tests than my peers.  My quality is average, and I’m more expensive.”  Is that amazing how I have been able to only work with the very best doctors out there?


Ok, I will now take my tongue out of my check and get serious.


The reality is that most doctors are very good at what they do.  The vast majority of doctors are also doing what they think is right for the patient and trying to be cost-effective.  I can tell you countless stories where doctors do the right thing for their patients and control costs even when it is detrimental to their business or paycheck.  Like any profession, there are bad actors out there.  There are bad doctors just like there are bad lawyers and bad politicians…. wait, that may have been a lousy comparison.  Anyway, the point to all of this is not that all doctors are good or that all doctors are bad but that in the new world of transparency and consumerism, you will have to prove your quality and cost-effectiveness or someone else is going to prove it for you.


Recently I have had clients receive what can only be described as a “report card” from one of their payers.  The payer will grade them on “quality” measures as well as cost.  What makes this even more real for the provider is the fact that payers are now basing reimbursement on these grades.  In addition to that, payers are actively selling narrow-network products.  If you are on the wrong side of the quality/cost line, you are excluded from these networks, which means those patients can’t come, see you.  When this happens, “stuff gets real.”


At first, many physicians have a very visceral and adverse reaction to being graded by an insurance company.  Statements like, “Who are they to tell me my quality is bad!”  and “What does an insurance company know about quality?”  are often the first things out of their mouths.  These are valid concerns.  Insurance companies have access to limited amounts of data, and several studies have shown that insurance company physician profiling is not very accurate or predictive.   There are many reasons why it’s difficult for an insurance company to measure and predict individual physicians’ quality and cost-effectiveness accurately, but that’s not the point.


The point is they are going to do it anyway, and it’s the world we live in.  Combine that with the rise of consumerism and the digital native populations’ use of this kind of information in purchasing decisions, and we have a whole new world out there.  A world where it’s not good enough to say you are high quality, you have to be able to prove it and respond to anyone who says you are not.


So, what’s a doctor to do?  Well, there are three things that every practice should start doing to be prepared for this new world.


First, from the top of the organization, you have to accept this new environment and adopt a culture of quality, self-reflection, and continuous improvement. Merely shouting at the wind that this “isn’t fair” won’t help at all and won’t stop the changes that are happening and will continue to happen.  Like a smart man once said, “If you don’t like change, you will hate being irrelevant.”


Secondly, develop or secure the knowledge, talent, and resources to evaluate and, where necessary, challenge any data about your quality and cost profile.  When a payer sends you a report card, the first response should be; “Thank you.  Would it be possible for me to see the data behind this report so that we can use it to improve?”  Yelling at the payer and complaining about the injustice of it all won’t help.  You need to engage the payer, or whomever else is producing the report card, and get as much data as possible.  When you find an error in the data or a reasonable explanation for the discrepancy, then point it out.  When the data shows gaps in your quality, then address it internally, close the gap, and do better next time.  Groups that do this well and quickly are going to do well in this new world.  Think about it for a minute.  If these report cards are good, you have an external source, a payer, verifying your quality.  Now you can see, “We are the best group in our area.  That’s not just our opinion; BCBS thinks so too”.


Finally, get proactive.  Develop internal measures of quality.  Make them the kind of criteria a payer would look at.  Analyze and evaluate your doctor’s performance against these measures and work with any of your doctors that are outliers while also trying to move the needle for all of your doctors.  If you know that a payer is going to measure how many of your female patients over the age of 50 are getting a screening mammogram, then look at your EMR data and make a point of talking with those patients that have not followed through with getting this done.  A couple of years ago, one of my Radiology clients wanted to engage a major payer on a quality argument.  Their position was that their callback rate on screening mammograms was lower than their competitors, and because of that, they saved money.  The payer did engage and did an exhaustive analysis.  The analysis showed little to no difference between the two radiology groups in town on mammo callback rates.  When my client did a deep dive into their data, they found that one doctor was driving up the group’s call back rates significantly.

Simply put, most of their doctors were better, but one doctor in the group had such a high call back rate that it was driving up the group’s average.  This doctor was an older physician that in all honesty, probably either lost some skills or didn’t keep up with his peers and the technology.  He probably should have retired.  The point to this story is that this group should have been looking at this data proactively, and they should have addressed this issue before approaching their payer partner.  I know these are hard discussions and that it’s difficult for a group to tell a long time partner that it may be time to hang it up, but that’s the world we live in now, and that is what successful groups are going to have to do.


The bottom line is this.  Change is happening.  Payers and consumers are going to grade and rate your performance.  You can be angry about this or accept it and develop the necessary tools and expertise to deal with it.


The choice is yours, and so will be the results.


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