MANAGED CARE January 2004. ©MediMedia USA
HEALTH PLAN 2009
Alice G. Gosfield is a principal at Gosfield & Associates in Philadelphia. She's a nationally known health care lawyer and a former chairwoman of the National Committee for Quality Assurance.
As health care expenses go up, dissatisfaction with the style of care with controlled costs will lead to more stratification in the industry in the form of more boutique, concierge, and pay-as-you-go elements in a world in which consumers carry more of the cost of their health care.
More stratification
Those who can pay will buy more amenities. While physicians and hospitals will seek to provide more of these amenity- and convenience-based "luxury" services, there will also be more stratification in terms of payers differentiating more among providers, allowing higher quality providers to be paid differently.
History to date has led to care that is paid for at the lowest common denominator or, at best, the middle of the curve. New approaches will go beyond pay-for-performance add-ons, but will allow truly different mechanisms of payment to coexist side by side as payer management systems become more sophisticated.
Bargaining
This will include more case rates and lowered administrative burden from decreased medical management and control features coming from plans that will bargain more explicitly for the level of care for which they will pay. Stratification will be developed to carve out 80–20 type conditions for different approaches, meaning that more attention will be paid to the bigger ticket/higher volume conditions.
Quality matters
This does not necessarily mean a $20 fee where other providers get a $10 fee, but more payment that reflects evidence-based medicine and quality performance.
Nonphysician practitioners will have increased responsibilities and legally recognized authority and will be included in global/team practitioner payment models, where physicians are saved for their highest and best use, permitting nonphysicians to perform more services previously reserved to physicians alone.
Some of this will be reflected in liberalized state laws that give to nonphysicians prescribing and procedural authority and some will be found in contractual payment models that put physicians in more of a supervisory and collaborative role on these issues, permitting nonphysician clinicians to actually be hands-on for the service.
As access to providers becomes more problematic in the midst of the malpractice insurance crisis of the early part of this decade, there will be state-level alternative compensation systems for tort.
Performance info
Far more information will be available regarding performance of individual physicians, physician groups, hospitals, and their medical staffs.
HMOs that survive in the year 2009 will have differentiated themselves among those that merely pay claims as being far more involved in helping their providers deliver appropriate care as opposed to merely administratively managing to actuarial projections.
Plans and providers will be far more connected electronically and will have more consistent IT systems across their enterprises so they can interact more quickly.
Fraud-and-abuse enforcement will flourish and expand far more into nongovernmental programs. Compliance will become more integrated into the overall health care mission and will no longer be an option for provider, plans, suppliers, and physicians.