Consider a chronic back pain sufferer. She wants to avoid surgery and anything that feels too invasive, but she doesn’t know there may be alternative treatment choices. What if her insurance plan and her doctor worked together, really collaborated, to determine the best care for her? They might suggest physical therapy, not surgery, as an initial approach. Recommending a nontraditional intervention as a competitive advantage might seem counterintuitive, but it’s part of a new way of achieving better results.
Changing Care for the Better
The nation’s health care system is in flux – transformational care that provides better patient experiences and outcomes is becoming more and more necessary. Current health care models can be disjointed, transactional, and complex, with go-betweens and multiple vendors acting as barriers to a more seamless, effective system. Through integrated health systems, some industry leaders are exploring new ways to foster true payer/provider collaboration that goes beyond a transactional relationship to become the kind of relationship that results in better patient experiences and outcomes.
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Creating Value for Patients
The “value agenda,” coined by Michael Porter and Elizabeth Teisberg in their book Redefining Health Care, is an overarching strategy that requires “restructuring how health care delivery is organized, measured, and reimbursed.” They present the need for providers to adopt a strategy that “transcends traditional cost reduction and responds to new payment models” while improving patient outcomes and growing market share. Defining “value” is a challenge many leaders are taking on in their own organizations as well as at C-suite gatherings like the 2017 Forbes Healthcare Summit.
“The classic definition of ‘value’ in health care is what you’re paying and the outcome you’re paying for. [Throughout the health care industry] what some patients are paying for may not be high value – there’s a lot of overuse and misuse and a lot of services or care that’s unnecessary or more expensive than it needs to be,” said Diane Holder, president, UPMC Health Plan, one of the leaders at the Forbes Summit.
The new winning reality? What’s good for the patient is ultimately good for everyone.
As a large integrated delivery system, where both the payer and the provider as well as academic medical centers are taking a “bench to bedside” approach, UPMC is exploring how to improve value for all. This means aligning the incentives among provider, payer, and patient.
For example, in medical homes, which provide comprehensive medical care aimed at obtaining the best health outcome, patients/members can see both their primary care doctors and specialists. The primary care physicians receive a wealth of data and information from UPMC Health Plan, including utilization patterns and other data that may not be available otherwise. This integration promises better coordination and collaboration and, ultimately, better care.
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Increasing Information Sharing
Sharing data can improve quality and reduce the total cost of care, and those savings ultimately benefit patients. The physicians’ and insurance companies’ incentives can align, which also helps patients because they truly value the care they are receiving.
“The ability to get care when they need it, get the right care when they need it, and get it in an affordable way are all big problems for patients,” said Ms. Holder. That’s why one UPMC goal is to better leverage and share data to provide the care people need, especially when more patients are paying out of pocket for it. Escalating health care costs, which are more than $3 trillion a year according to the U.S. Centers for Medicare and Medicaid Services, are contributing to patients’ desire to want more for their money.
Partnering for Change
Patients like the chronic back pain sufferer are now able to get relief by having more information and a team of physicians, therapists, and insurance specialists who partner to create a personalized treatment plan instead of defaulting to surgery first.
UPMC is at the forefront of this health care transformation, with a goal to deliver the right services to the right patients at the right time. In doing so, it will be among the health systems that are creating real value – improved outcomes and patient experience – and gaining a competitive advantage that’s sure to deliver future growth and sustainability.</p>
Headquartered in Pittsburgh, UPMC is a world-renowned health care provider and insurer. We operate 40 hospitals and 700 doctors’ offices and outpatient centers, with locations in central and western Pennsylvania, Maryland, New York, and internationally. We employ 4,900 physicians, and we are leaders in clinical care, groundbreaking research, and treatment breakthroughs. U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside as one of the nation’s best hospitals in many specialties and ranks UPMC Children’s Hospital of Pittsburgh on its Honor Roll of America’s Best Children’s Hospitals.