The Arizona Hospital and Healthcare Association (AzHHA) has been trying to help the business community become more effective in doing business with insurance plans.
“One thing we’re seeing is that as we go through payment reform — from volume to value — there are some business challenges as systems try to integrate the new model when parts of the old and antiquated model are still in place,” says Greg Vigdor, president and CEO of AzHHA.
Az Business talked with Vigdor about how the business of healthcare is changing.
Az Business: Why do you need to educate the public about doing business with insurance plans?
Greg Vigdor: Part of what you hear is how we’ve moved into new ways of paying for healthcare and there are all kinds of opportunities for businesses to buy care differently and it’s great because it’s going to promote value instead of volume. The reality is that most of healthcare is still working with these somewhat Byzantine payment systems that reward volume and incent the insurance companies to play these transactional games to make their business work — claims denials, slow payment of legitimate claims. So we’re not in this new model, yet we’re still operating in this old model. The way the system is being gamed presents problems for providers and those problems trickle down to a business’ employees.
AB: Can you give me an example?
GV: An issue that keeps coming up is “surprise billing” and how to resolve it. There is usually a fight between the person getting the care and the health plan and the provider. We’re trying to figure out how to develop a policy so the person is not stuck in the middle. We think the health plan is the one that needs to be more clear about what the person gets billed, how the system works and how the payment dispute is resolved. We’re trying to settle that world for not only the providers, but for the consumers.
AB: How do you hope to settle that?
GV: We are trying to figure out how to partner with the health plans on a host of issues, including how to do value-based payments. How do we reward doing the right thing, creating value and creating health? That should be a partnership between providers and health plans. It’s where the system wants to go.
AB: How can business leaders do a better job dealing with insurance plans?
GV: The most fundamental thing they can do is understand when they select health plans for their employees, be conscious of the next level of choices for the employees and how it’s going to work. It’s more than just looking at it and saying, “We got a cheaper price.” The value is not just what you’re paying up front, but how does it actually work for your folks? If you find a new health plan and it doesn’t work for your employees, it’s not going to do much for morale or productivity. the best advice I can give is to try to work with a good broker who can help you navigate the full decision.
AB: How is payment reform impacting the healthcare industry?
GV: It’s creating a lot of trepidation. The uncertainty is off the charts. Where is the value equation if you’re already looking at a negative bottom line or a very small bottom line? As you start to look at what you need to do to move to the new models, it’s a fundamental shift. It’s still unclear exactly when it’s going to happen. Some people think it already happened. It might happen in three to five years, but it could be five to 10 years. So if you flipped your business model to respond to payment reform immediately, you’d probably go out of business. Right now, you’re rewarded for doing more tests and more services and if you suddenly stopped doing that, you’ll find out you don’t have any money. That’s the angst we’re feeling out there.
AB: What is the best way to tackle payment reform?
GV: It involves working with physicians who have historically been independent practitioners and not your typical employees. So it’s figuring out how to work with that very complicated world with very bright independent-minded folks. It’s also very much caught up in information systems technology, which is a huge financial investment. So that’s also part of it: when do we make that investment if we’re not really being paid that way? It’s a paradigm shift in the industry.
AB: What are the other major uncertainties?
GV: Unlike other changes we’ve faced in healthcare where the government is involved, we’re not really sure we can count on their timelines. If Donald Trump becomes president, what does it mean for all this? We don’t have a clue. We don’t have a much clearer picture if Hillary Clinton becomes president, but if Donald Trump becomes president, it’s a wildcard. Will all this come to a screeching halt?
AB: Are we are going to see an increase in the number of businesses who self-insure?
GV: Yes, it’s just when? Paradigm shifts happen quickly and until enough businesses get into that, we hang onto the old model. We are still far away, but I expect it to grow experimentally and there will be a flashpoint where people say, “That old system doesn’t work very well,” and it will be time to do things differently and things will start to change immediately and it will be a whole new world.
AB: What are AzHHA’s priorities or goals for the next year?
GV: Dealing with the shift to value-based payments and redesigning the system. A lot of it has to do with what is described in healthcare as the “triple aim” — create lower cost, better care and better health. Our job is not just to treat sick people, it’s actually to keep people healthy, so how do we do that better?
