Navigating the complicated world of health care

These days, it’s hard for patients and other health care consumers to know if they have access to the best doctor, facility, or medication for a specific situation, even if they have a “preferred network,” center of excellence, or a well-known pharmacy benefit manager. Patient satisfaction surveys and self-reports by physicians or facilities are subjective and provide only “nice to know” information— like bedside manner or convenience of hours or of the  scheduling system. But there’s also plenty they don’t tell you, like how well your knee will perform post treatment, for example. 

Without objective, third-party scores for health outcomes and clinical studies, it’s nearly impossible for a member to make an informed decision. Relying on word-of-mouth recommendations, patient satisfaction surveys, or provider self-reports may not always lead to the best outcomes. Even your health plan or network may not be as effective as you think it is, regardless of the carrier or design.

While having access to a wide network is beneficial, it’s not enough. Narrow or high-performing networks (HPN) or centers of excellence (COEs) only tell part of the story. So, how can employers assist members in receiving the right care from the right provider at the right time? The answer lies in providing members with easy and informative tools to navigate their choices within their network using unbiased and third-party data. And they must be easy and compelling to use.

Cost and quality navigation overlay programs can help. They sit on top of the carrier’s network, providing actual, real-time data about health outcomes and fair pricing. By using sound data, members can make informed decisions about their health care choices, ensuring that they receive the best care possible at the best possible price. It turns out that costs vary widely, sometimes by several hundred percent for the same treatments depending on where and who performs them. Even within the same zip code. With effective communication strategies to engage members year-round, overlay programs do not disrupt the plan. They enhance them.

Health plans are contractually obligated not to share information about the quality of care of specific facilities or providers within their network, which is why even a “high-performing network” or other network strategy may not necessarily offer the best quality of care. These networks are designed to indicate cost efficiency for the plan. And guess what? High cost has not proven to result in better outcomes when it comes to health care. Additionally, health outcomes can differ significantly between different facilities, even if the same doctor is providing the same treatment at both.

This is true even if the facilities are part of the same hospital or health care system and have the same name. To ensure the best possible care is received and at the fairest price, access to unbiased data about health outcomes and treatment options is available through cost and quality overlay programs. Without it, no one can make the most informed decisions about healthcare.

Why, though? Why, if it is the same treatment/procedure by the same provider, would there be different outcomes? Or even different prices? Simply put, because the doctor is not the only person, process, or protocol involved in care. Health care is more than just the provider; it involves complex systems which vary from place to place. Even if the places are affiliated with one another and nearby.

Moreover, just because a doctor excels in one procedure doesn’t mean they excel in all procedures, even within the same specialty. Networks and centers of excellence offer only a partial picture of the quality of care, and typically do not provide granular data on exact health outcomes for specific treatments by specific doctors at specific facilities.

When seeking care, thanks to overlay programs, we can now take into account all these variables in concert: the provider’s track record of appropriateness of care, the prescribed treatment (including risk and volume adjustments accounting for comorbidities), and the facility. Considering the outcomes of these factors together rather than in silos ensures better outcomes and at the fairest prices. For example, if you need knee replacement surgery or a breast biopsy, you want to know about the outcomes and costs of the doctor and facility for that treatment. 

Crowdsourcing health care recommendations from friends, family, or coworkers can be risky, because their experiences may not be relevant to your specific health issues and history. Recommendations require consideration of all relevant factors, including the facility, treatment, and doctor. Similarly, selecting a school district for your children based on reputation alone does not guarantee optimal education. You must also consider the specific school your kid will attend, your child’s teacher and their mastery of the subject being taught to your little one, along with the teacher’s results particular to the subjects taught and special needs of your child.

Or think of it this way: Going to the grocery store is like navigating the health care system. While you have access to all the foods and products there, you need to go deeper to find the right ones that meet your specific needs at the fairest price. Similarly, employers offer a great benefit by providing health plans, yet ensuring that the members receive the best care requires an extra step. And our industry now has the data and the technology to make it an easy one. By using a cost and quality navigation overlay program with tailored communication and education strategies, employers and brokers can rest assured knowing that employees make the best use of their insurance, receive the best care possible, and that the plan and the members are not overpaying for their treatments the first time around. No one needs to settle for subpar care or overspending when readily available cost and quality navigation solutions exist to maximize the benefits you already offer.

Gentry Lynn is a cost & quality strategy analysis consultant at Healthcare Bluebook.