Healthcare Stakeholders: A Perspective

We're delighted to welcome guest-blogger Deron Schriver, blogmeister of Healthcare Rx. Deron recently proposed a post about physician/insurer relations, and we're happy to oblige. He's worked in the health care field for for ten years, with the last three spent as a medical group administrator for a large OB/GYN practice. Deron tells me that his "daily interactions with the various healthcare system stakeholders have enlightened me and sparked my interest in system reform, which has lead to my other life as a rookie healthcare blogger."

Deron believes that there is a tremendous amount of room for improvement in that area. Given today's political climate, this seems like a capital idea, and we are pleased to present his take on where we "go from here:"

The high per capita spending of the U.S. healthcare system has been widely published. As a result, we have seen a renewed interest in system reform. Despite the large number of people and organizations developing and proposing reform strategies, no single strategy has emerged as the best solution.

Considering the magnitude of the problem, we would be best served if we could identify synergistic reform opportunities. I would like to suggest one very important opportunity that could produce significant benefits: a focused effort to improve and enhance the relationship between physicians/hospitals and health insurers/managed care organizations (MCOs), with a goal of improving quality and reducing cost.

In a well-functioning healthcare system, providers and payers would partner in the name of improving the health status of their mutual customers: the patients/covered members. However, patient-centeredness has taken a back seat in the current environment. Factors such as market share and leverage have played a big role in fee schedule negotiations and provider network development and maintenance. Instead of identifying common goals and opportunities to work together, the two sides have been guided by short-term financially-motivated thinking.

So where do we start with an initiative like this? My suggestion is that we get the two factions to sit down and discuss 1) the measures they can take to improve the health status of their mutual customers and 2) the steps they can take to reduce waste and complexity in their relationship.

The two must identify key indicators to help guide their efforts. Clinical measures such as average spending per condition, hospital infection rates, and screening rates (mammograms, cholesterol checks, bone density tests, etc.) should be routinely analyzed and acted upon when necessary. Administrative measures such as claim denial rates, phone hold time, and consistency of policies with national standards (ex. CCI) should also be considered.

As someone who sees this relationship play out on a daily basis, I can tell you that there is tremendous room for improvement. Turf protecting is a big problem within the U.S. healthcare system, and all stakeholders, particularly the two mentioned, engage in it routinely. If it’s done right, reform does not have to mean that insurance companies, physicians, or any other stakeholder needs to take a big financial hit. Reductions in revenue will be offset, to at least some extent, by corresponding reductions in cost. When the focus is where it needs to be, waste will be eliminated and everyone will come out stronger. This is a best-case scenario, but I can’t imagine striving for anything but the best.

Many, many Thanks, Deron! It's obvious that there's a lot more to the challenge of health care delivery and financing than meets the eye, and that a good place to start is by opening up these lines of communication between providers and insurers.