Health Insurance brokers connect employers and other plan sponsors with health care benefits solutions, adding value by matching plan sponsor needs with a range of benefits within budget requirements.
Whether seeking fully insured or self-insured solutions, brokers are the primary liaison for plan sponsors with millions of lives nationally — navigating benefits solutions, dealing with coverage and claims issues and giving plan sponsors a voice.
Fortunately, as the health care paradigm shifts from quantity to quality, brokers who speak the language of value-based care are poised to thrive. The transformation has been a long time coming. In fact, it’s the result of decades of gradual change toward precise quality measurement and efficiency of providers, as well as development of systems to monitor and administrate the incentives or performance thresholds in health care.
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As we delve deeper into the workings of value-based care, a couple of key phrases to understand:
Value-based insurance design underwrites benefits designed to promote high quality and cost-efficient health care services, rewarding plan members for using high value services and high quality providers.
Value-based reimbursement incentivizes providers to deliver high quality, efficient, care administered through various models. These can be managed as bundled rates, case rates population health measures, patient engagement improvement, performance guarantees or a host of other arrangements.
Tapping into value-based data
Unlike the traditional fee-for-service model, the new value-based care approach requires credible data to enable providers to precisely measure quality, determine the overall health of populations, report outcomes to plan sponsors and demonstrate achievement of the level of value contracted or remediate poor outcomes.
The challenge: Significant variance in quality and cost outcomes still exists across hospitals and physicians nationally, including statistically different rates of mortalities and complications to unexpected readmissions and adverse patient safety events.
Additionally, differences in price per unit and resource utilization across all care settings account for up to a five-fold difference in claims cost, making value-based purchasing complex to assess and administrate.
Nevertheless, these outcomes are now central to the value-based conversation, and key differentiators in using effective solutions to improve quality and lower spend.
Safety + quality = value
Many brokers remain uncertain about the relevance of safety and quality in achieving greater value in health care spend, but it’s important that they become conversant on this topic to remain viable partners.
The key is to find a solution that helps clients: evaluate quality of care based on academically reliable and scientifically sound methods and clinically adjusted utilization profiles; understand the metrics; and after gaining a clear picture of provider quality, safety, and utilization put a plan in place to move towards value.
It’s important for employers to get a clear view of high-quality doctors who can provide services at optimal costs and encourage plan members to use these services and achieve better employee health outcomes with potentially lower spend.
Brokers must understand that much of today’s perception of value is based on brand equity not a comprehensive, multi-dimensional view of actual provider performance. Providers that achieve excellence in orthopedics, for example, may not deliver high quality in general surgery. As such, you must be able to assess performance across all clinical areas to compile an accurate picture of the markets for your plan sponsors.
Additionally, you will need to have a deeper understanding of the methods employed by various agencies to rate providers. Several hospital ranking organizations — U.S. News & World Report, Healthgrades, Truven, Centers for Medicare and Medicaid Services (CMS), Leapfrog — reflect substantial levels of variation in the results primarily due to their methods and data sources.
Many of these organizations use reputation-based or self-reported survey data, single dimension scoring that omits key quality measures and domains and is not properly risk-
adjusted for accurate analysis of outcome and performance. Many of these approaches fall far short of the rigor and specificity required to truly understand the value being delivered.
For example, in 2017, U.S. News & World Report postponed public release of its annual hospital rankings after it discovered errors in the data used to compile its report. In 2016, only 102 hospitals received the top rating of five stars, and few of those were considered as the nation’s best by private ratings sources such as U.S. News & World Report or viewed as the most elite within the medical profession. CMS has also come under fire for the manner in which they represent their ratings to consumers.
Addressing patient safety
Patient safety performance is also largely unknown for insurance carriers and third-party administrators. Therefore, brokers have an opportunity to elevate patient safety as an additional consideration when evaluating network performance. Asking questions around how providers are credentialed for safety is a good place to start.
The good news is that more organizations are emerging to offer products and services for bundled care, transparency in pricing and quality, centers of excellence and many others. To the extent that brokers understand how these products deliver predictable pricing and quality allows them to be in a far better position to assist their clients in lowering spend and improving outcomes.
These models can be carved out or offered as options to plan members with incentives. Whether clients adopt these services or not, brokers can differentiate themselves by guiding clients toward health care that is safer and higher quality for the benefit of plan members.
Originally posted on BenefitsPRO.com