Payment reform: A marathon, not a sprint


There's been a lot of chatter among health insurance execs, consultants and industry experts that payment reform is a positive change. An absolute necessity, in fact.

So why, then, did a recent study from the Catalyst for Payment Reform conclude that only 11 percent of insurers' reimbursement payments to providers were tied to quality and efficiency of care?

"Nine of every ten dollars is paid into the healthcare system with no attention to whether the care provided was performed well or poorly, or whether it was appropriate in the first place," said CPR Executive Director Suzanne Delbanco.

In addition to the myriad articles about how insurers are transforming provider payments, I've interviewed numerous payer executives who detailed their own programs. Insurers like Aetna, WellPoint and UnitedHealth are leading the way, all announcing last year that they are overhauling payments to incentivize providers into offering more quality care.

Smaller payers too, like CareFirst Blue Cross Blue Shield and Premera Blue Cross, have worked to pay providers more money when they meet certain quality goals. And that's just to name a few.

So how can it be that the remaining 89 percent of reimbursements are either traditional fee-for-service or bundled payments not associated with quality, value-based care?

Although we should admire and appreciate these insurers for taking the ever-important first steps to depart from fee-for-service payments, even more steps must be taken. But the solution is just as complicated as the problem is deeply embedded within the healthcare industry.

Insurers can't simply snap their fingers and make all doctors, hospitals and other providers completely alter the way they've been operating for years. They can help initiate new payment methods and work to recruit providers to these new models, but they certainly can't place all responsibility for payment reform onto their own collective shoulders.

Instead, true and widespread payment reform requires a complete overhaul of the much-maligned, yet deeply entrenched, tentacles that fee-for-service holds on the healthcare culture. Doctors have to approach healthcare in the holistic, whole-person method that represents true patient-centered care.

It involves providing more preventive care, ensuring patients receive certain screenings. It means better communication and coordination among all providers caring for a patient.

It might even mean recommending more alternative care methods, including acupuncture, message therapy or chiropractic services, for patients with chronic health problems. And it means talking about wellness options, such as healthful eating and exercise habits, more often with patients.

It means writing care plans, reaching out to patients to ensure they take recommended next steps and eliminating gaps in care. It might mean incorporating some sort of technology, including electronic health records, to enable these changes.

The work, therefore, to move away from volume to quality is enormous. Although many of the necessary steps already are in motion, by both insurers and providers, the transformation is a marathon, not a sprint. It likely will take years to completely restructure provider reimbursements.

We probably won't see widespread, discernible effects of payment reform in the next few months. But we could witness small, concrete results along the race, and those are to be as celebrated as actually crossing the finish line. Every tiny step that insurers can take boosts their ability to reach the end goal.

So although the CPR study seems dire on the surface, I think it should actually be taken as a demonstration that reform is in motion, albeit slowly. And I can only imagine what the future holds for the healthcare industry. - Dina (@HealthPayer)

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