High Performance Provider Networks and HDHP

Monday, November 29, 2010

Although high performance provider networks may be found in conjunction with any form of health care plans, they are most effective when linked to a High Deductible Health Care Plans (HDHP). Since consumers are on point to spend a significant amount of their own moneys as a HDHP member to obtain health care, it becomes imperative that they get the best care possible for the lowest cost possible. If the organization’s goal is to move increasing numbers of its employees to a HDHP, current members must be able to show that their experiences were highly positive. This applies to both the treatment received and the long-term financial impact. Current HDHP members are not going to support continued participation if they do not receive effective and efficient health care if it lacks quality.

Increasingly provider networks are being rated on their use of best medical practices and evidenced based medicine. From a layman’s point of view, best medical practices and evidenced based medicine may be defined as the standardization of medical diagnosis and treatments practices to optimize outcomes and recoveries based on medically documented results and substantiation.

Harvard Medical School offers a continuing education course titled,: “Best Medical Practices: Maximizing Skills, Minimizing Risk”. The two-day seminar included topics on state-of-the-art diagnosis and treatment, safety and effectiveness, patient communication skills, and medical malpractice.

The national Blue Cross and Blue Shield Association maintains “Blue Distinction designations” as a means to identify and designate those medical “facilities that have demonstrated a commitment to quality care by meeting objective, evidence-based thresholds for clinical quality and safety developed with input from expert clinicians and leading professional organizations.” Blue Distinction centers focus on:

          • Bariatric Surgery

          • Cardiac Care

          • Complex and Rare Cancers

          • Knee and Hip Replacement

          • Spine Surgery

          • Transplants

In January 2009, Cigna reported on the use of “more than 300 evidence-based measures of health care quality” to evaluate the effectiveness of over 400,000 Cinga members in its HDHPO, HMO, and PPO plans. Cigna’s conclusion was that adherence to “evidence-based measures” has a positive relationship to both the quatitlty of care and the cost of that care.

The Ohio Association of Health Plans (OAHP), a statewide association of health care plans with more than six million Ohioans, promotes its member plan’s use “of best medical practices” and “delivery of evidence based health care”.

During an October 22, 2010 presentation, Booz & Company, a global management consulting firm to businesses, governments, and other institutions, identified “Narrow, high performance provider networks” as a “key” capability in the emerging health care industry following health care reform.

The operative word is “narrow”, rather than accepting “any willing provider”, a high performance network accepts only those providers, which are able to meet and maintain a high degree of professional and medical standards. The result is often a smaller network, yet a network with highly effective and efficient providers practicing medical best practices based on evidence based medical.