Government can't be everywhere

URAC is helping steer organizations on the road of quality, offering 16 accreditation programs including those for traditional medical management functions, Web sites and consumer-directed efforts. Its seal is recognized in 37 states, the District of Columbia, and by several federal agencies.

Its president and CEO, Alan Spielman, says URAC has an opportunity to lead healthcare's quality platform even as the incentives change. "I am bullish about the value of accreditation, and I am bullish about URAC," Spielman says. "It has in its governance a wide range of different players in the healthcare arena ranging from the providers, consumers, regulators, purchasers and plans, and that's coupled with an inclusive process to develop the standards so they're able to balance the views of all sides."

"Healthcare is extremely complex," Spielman says. "Government will establish new requirements for its programs, but government can't be everywhere." That's why industry-established best practices are so critical.

In 2006, nearly 50% of the nation's healthcare bill will be the responsibility of some federal or state government program. In one year alone, from 2005 to 2006, Medicare will increase from paying 2% of the nation's pharmaceutical bill to 28%, he says. The government's stake is high and rising higher.

However, plans, payers, employers and consumers are also feeling more of their skin brought into the game and want value for their dollar now more than ever. Spielman says three drivers are shaping healthcare's higher stakes.

First, chronic care needs for the entire population are growing with the biggest rise happening among seniors. Baby boomers have approached retirement age, and their service utilization is trending up. At the same time, Spielman says, diabetes among younger people in this country "is going off the charts." More people need more care, and that drives costs and desire for value.

Also, consumer-directed healthcare (CDHC) models have caused a shift in incentives and business processes, which is yet another far-reaching change, he says. CDHC is more than just another benefit design offering, it's a new model that puts comparative value propositions in front of consumers.

Finally, Spielman says, there are quantum changes in medical technology, biotech and specialty pharmaceuticals. Technology has opened the door on many new solutions in ways never seen before, which breeds the necessity to manage and justify the cost/value equation.

Those three drivers-increased chronic care needs, CDHC and medical advances-present opportunities for the industry to balance its needs and align its incentives.

"We cannot look to government for the solution to all things in healthcare," Spielman says. "We all want affordable care, and it's easy to say why not just pass a law that says we don't have to pay more next year for drugs or hospital care. But price controls don't work."