The Twin Crises of Healthcare by George Isham, M.D.
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George Isham, M.D., M.S.
Chief Health Officer and Plan Medical Director
Recent health care news coverage has focused on the concept of tiering and its affect on a patient's ability to choose where they receive their care and the influence tiering may have on physician practices. The focal point of these stories has been mostly on the cost of health care. And, cost is important, as last year the American medical bill was more than $1.5 trillion.
Unfortunately, there hasn't been enough focus on the other health care crisis poor health care quality. Despite the hefty price tag of health care, recent studies have shown that Americans only receive approximately 55 percent of the appropriate care they need.
For tiering to be effective and have a significant impact, tiers must weigh cost and quality equally. Low cost providers shouldn't be given a free pass as being among the best, and high quality providers who charge extraordinary fees also need to be scrutinized. With cost and quality weighed equally in tiering, consumers and employers gain a clear picture of who is doing the best work, and also who is affordable. For providers, tiering gives recognition to providers who deliver quality care, while giving other providers a guide for improvement. It is important that tiering does not penalize providers for their work, or where they send their patients for specialty or follow-up care -- there needs to be flexibility for choices to be made.
HealthPartners has been publicly comparing the quality of health care providers in Minnesota for 15 years and has offered a tiered network for almost 10 years. With our tiered products, we have more than 70 quality measures that are weighed against what a provider charges. The quality measures focus on many things including physicians using evidence-based, best-practice medicine, patient satisfaction, advice to quit smoking and patient safety. By linking quality and cost together, we know members that pick a tier I provider will receive better care with less out-of-pocket costs. Consumers and employers have responded, as today more than 150,000 members participate in a tiered network product.
Unfortunately, because cost and quality are not usually linked together, we have significant waste in the American health care system. The system is inefficient and in many cases, we are either not providing enough care for our patients or we are providing too much care. To maximize the benefits of our health care system, we need to remake it so that the right amount of care is being delivered -- tiering helps make that happen. For a diabetic that doesnt receive good care, who doesn't watch their diet, who doesnt exercise, they cost the health care system more than $60,000 each year. For the diabetic who does receive good care and is proactive in leading a healthy lifestyle, their costs to the health care system are just over $5,000 for the year. This range of cost is a direct effect of poor quality health care.
In Minnesota, we are fortunate. The quality of health care in Minnesota is rated as being the best in the nation. In fact, Minnesota has been the top-rated state in health care delivery for nine of the past 15 years. The other six years, Minnesota ranked second. But, even as the best, we still have a long way to go. In 2004, Minnesota diabetics received appropriate care just 18 percent of the time -- and that leads the nation. This year, for diabetes care, there is a stretch goal of reaching 30 percent of patients receiving appropriate care. If we reach that goal, it will be a fantastic first step towards improving health care quality.
Health care costs are going to continue to rise until we start addressing the quality crisis. We can not control costs until wasteful spending is eliminated and we begin giving patients the care they need, when they need it.
George Isham is Chief Health Officer and Medical Director for HealthPartners.
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