Lowering costs to increase access

If you caught only the headline of a lead Washington Post story online and in print last week, you might get the wrong idea about what many health care thinkers actually consider a tenet of health care reform: “Insurers restricting choice of doctors and hospitals to keep costs down.”

A closer read of the article reveals that the lean toward smaller networks is not a secret that insurers want hidden from consumers; nor do standards of value and quality of care make insurers the enemy.

The state and federal health insurance exchanges were designed to keep premiums down – a goal most Americans can get behind. Many insurers and health plans now scrutinize providers for quality and performance measures before committing to them.

Cost can also be a factor in that decision-making. For example, while large academic facilities can provide specialty treatment unavailable elsewhere, they often charge thousands more than community-based hospitals for routine care, according to the Post article.

But insurers are not concerned with cost at the expense of quality and outcomes. Instead, many health plans, including ACHP members, are steering consumers toward the best overall value. That means measuring how often patients receive preventive tests and vaccines, how well care teams manage chronic diseases and how effectively those care teams prevent discharged patients from being re-hospitalized. Not every hospital and physician will make the cut. Insurers are slimming down networks to hold providers accountable by offering only the best, most affordable care.

ACHP member plans are committed to quality. Our organizations care for 17 million Americans – less than 7 percent of the nation’s total insured population – but claim more than half of the top 25 Medicare, Medicaid and commercial plans as ranked by NCQA and more than 20 percent of the 4-, 4.5-, and 5-star Medicare Advantage plans as rated by the Centers for Medicare and Medicaid Services (CMS). These scores are designed to help consumers determine the best plan for their budget – a relationship to health care Americans should be able to expect.

A recent Commonwealth Fund report reminds us why the U.S. health care system as it exists now begs for change. The U.S. outspends every nation on medicine yet falls short on virtually all measures of cost and care. Notably, adults in the U.S. are significantly more likely to risk financial trouble in accessing care or forgo needed treatment due to high costs.

While networks on the exchanges may be smaller than consumers expect, the exchanges are primarily meant to reach the millions of Americans whose insurance options are too costly, too limited or non-existent. Lowering costs to increase access comes with some trade-offs, and we need to do a better job in informing Americans on what they are. Reform demands rigorous attention to quality and value, as well as consumer education.

-Sophie Schwadron
ACHP Intern