I've had
three really interesting experiences lately that have got me thinking more
deeply about employers and their role in determining our health care coverage. We
all know that "employers want to reduce health care costs." But I saw that in
action three different times in less than two weeks.
I was talking
to two different local health care collaboratives about what they're doing to
promote quality. What's a health collaborative, you ask? Well, it depends. In
one situation, it was basically a small insurance company—kind of like a
collective of employers who banded together to form a larger (and hopefully
cheaper) insurance pool. Besides decreasing costs by creating incentives for
doctors and systems that meet quality markers in treating major chronic
illnesses like diabetes, they also create performance metrics that show each
provider and system where they stand in terms of cost effectiveness.
This is a
precursor to creating tiered reimbursement systems, similar to something I
talked about in one of my earlier blogs. While a tiered system is supposed to
reward the doctors who are high quality and low cost, what we consumers fear is
that it will do something else entirely. A tiered system might result in
doctors and hospitals "cherry picking" only the least complicated and easiest patient
populations ... leaving those of us who are sicker to higher-cost, lower-quality doctors.
Who's
demanding this tiered system? The employers, of course. There seems to be a
ridiculous assumption among employer groups that all illnesses are equal and everyone
with a mental illness will respond in exactly the same way to treatment. Under
that assumption, "quality providers" would be those who saw more patients and
spent less money doing so, as well as those who followed specific "treatment guidelines"
versus those who didn't.
Mental
illnesses are complicated. For example, 60% of us live as consumers with a
substance use disorder, 41% of us smoke and a high percentage of us have other
co-occurring illnesses like diabetes, heart disease and the like. It seems very
clear that a tiered system won't work well for those of us with complicated
illnesses, illnesses that don't respond to treatment right away or those complicated
by other co-occurring illnesses.
Adding to
that, nobody responds to any single medication or treatment plan in the
same way. This means that the quality guidelines for, say, depression are very
odd. Why is seeing a depressed patient three times in 12 weeks after the first diagnosis
a quality measure? Just seeing the patient says nothing about whether quality treatment is occurring. It's
a process, not an outcome. Indeed, DBSA's surveys show that most of us define
quality in ways that are completely different than these so-called "quality"
indicators.
This was
hammered home to me when I participated in a very small, high-level group
trying to select quality and efficiency measures within a large insurance
company. There were maybe 14 of us at the table, and only three of us were from
outside the company. I was the only consumer/consumer voice at the table. I was
listening as this company struggled to find some realistic way to measure
quality effectiveness, and it became clear they were doing this because the
people who buy their insurance (employers) were demanding it. The insurance
company executives knew they didn't have the data needed to show true
quality and efficiency in ways that would put the consumer first. But they were
being pushed to do it anyway. I was very, very impressed with the executives at
this meeting, because they simply would not cave in to the demands of these
people, the primary purchasers of their products. Instead, they went through
the process of creating a system that actually could measure quality and
efficiency based on outcomes (not processes) and consumer experience.
