Marie Rosenthal

Among the decisions employers are tackling is whether to keep their group health plans. A new report by Truven Health Analytics says that large employers would fare better by continuing to provide health benefits through a group plan, rather than paying large penalties as employees move into exchanges.  

"There is no scenario where both the individual and the company benefit by moving the employee into an exchange and not offering benefits," says Ray Fabius, MD, chief medical officer at Truven Health Analytics. 

Truven examined several scenarios, such as eliminating coverage but providing employees additional compensation in such a way as to make the move cost-neutral to employers. Should employers choose to eliminate group plans without giving employees subsidies, the cost to the employee for coverage would be about $16,550 per year. Such reductions in total compensation packages would likely drive employees away, which would make the employer less competitive, Dr. Fabius says.  

Such industry changes will drive further optimization in plan design to control health costs, according to Thomas Heatherington, senior payer executive at Accenture Health.  

He says research shows that payers spend more than 75% of revenues on medical costs that remain largely out of their control.  

"In the same way that successful retailers have developed new ways to identify and serve their customers, successful health insurers should create the ability to think about consumers in new ways-as individuals and households with behaviors and preferences that drive their healthcare consumption and well-being," he says. 

The health-reform law's intent is to maintain the number of Americans covered by their employer and encourage more employers to provide health benefits, Dr. Fabius says.  

 "Health insurers are refining and scaling their operations to deliver the right level of service to the right consumers at the right time," Heatherington says. "The result is that insurers will increasingly adopt new business models, diversify their offerings and provide broader, more holistic services to consumers." 

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Among the decisions employers are tackling is whether to keep their group health plans.

Shifting employees to exchanges provides no real advantage

Healthcare reform has been a tumultuous journey, but there are signs that transformation is occurring despite Congressional wrangling. One of those signs is the ongoing creation of accountable care organizations (ACOs). 

The National Committee for Quality Assurance (NCQA) recently released accreditation standards for ACOs in the private and public space.

"The committee did not want people out there with training wheels on calling themselves an ACO," says NCQA's president, Margaret E. O'Kane. "We have a fragmented healthcare system with many redundancies and disconnects. There are all the wrong incentives in place to do too many things that do not add up to a comprehensive and coherent care plan." 

Charles Kennedy, MD, chief executive for Aetna's accountable care division says the industry has good reason to feel optimistic that the delivery system will become more efficient, more effective and more convenient as ACOs mature. Having a roadmap to follow will be crucial for those beginning the journey.  

"ACOs are a new concept without much of a track record as to how to create and execute the necessary business function to provide value," Kennedy says. "Accreditation will provide a checkpoint for organizations going down that path so they can demonstrate to health plans, employer groups and individual patients that they have met the basic criteria to become an ACO."  

An ACO reinvents care delivery by providing a different structure that ideally would reduce fee for service and result in more cohesive, value-driven care. 

 "Traditionally, the healthcare industry has not been a healthcare system; it has been a healthcare sector," says Dr. Kennedy. "Except for a few integrated delivery systems, physicians and hospitals were not organized to deliver cohesive care, but integrated systems tended to deliver a higher quality of care at a lower cost." 

Studies have shown that there is no correlation between the cost and quality of care. He says providers can deliver high-quality care efficiently or deliver high-quality care inefficiently. The ACO market aims to create an incentive to deliver high-quality care efficiently. 

Accreditation could increase the cost of becoming an ACO, but it can be minimized if organizations structure their ACOs from the ground up with accreditation in mind. In addition, many providers can turn to payers for help. 

"I think the cost estimates for becoming an ACO will vary widely depending on how the ACO is created," Dr. Kennedy says. "Third-party payers can help providers become ACOs at a much lower cost because we bring to bear many of the components that ACOs need to have, which is the health information technology and quality management functions."  

Another concern is that meeting the standards set by NCQA will decrease an ACO's flexibility to respond to its patient population. Patricia Barrett, MHSA, vice president product development at NCQA, says flexibility and standards are not mutually exclusive. Accreditation will determine basic standards that ACOs must meet to create value for the patient, but it won't dictate how that standard is met.  

"For example, ACOs have population management requirements, but who performs the function is not as important as the fact that patients receive that benefit," she says. 

The standards will not outline explicit quality management activities, for example, but ACOs must have a quality management system in place. The accrediting body would review the program comprehensively to make sure it is designed to improve quality. NCQA will require at least 5,000 patients represented for accurate scoring of the ACO for accreditation. 

Just as hospitals and health plans have objective third-party scoring, ACOs will probably be expected to have accreditation, too.  

"An accreditation process will likely become a requirement or at least, commonplace," says Aetna's Dr. Kennedy. "As to whether it is NCQA or other entity, I can't say, but NCQA has a strong record." 

Douglas L. Chaet, senior vice president, contracting and provider networks at Independence Blue Cross, and MHE editorial advisor, adds that the new guidelines will influence the way some ACOs build their delivery systems.  

"We expect that these accreditation standards will be carefully considered by entities considering becoming an ACO," he says. 

ACOs will be expected to have accreditation as a minimum standard.

Author | Marie Rosenthal

Articles

Shifting employees to exchanges provides no real advantage

NCQA accreditation provides roadmap to accountable care