In-Network Provider Quality Varies Significantly... Implications for Employers
By: Eric Bricker, MD
PPO networks at the major insurance carriers are so large that +90% of claims are in-network. That’s great.
However, there’s a flip side… PPO Networks are so large that they have high degrees of doctor quality variability within the network.
By definition, not all doctors can be above average. However, having an above-average doctor can be a tremendous help to patients regarding major health issues such as cardiovascular disease, cancer and musculoskeletal pain.
Let’s now examine these three diagnostic categories because they are the illnesses that drive the greatest amount of healthcare spending for employer-sponsored health plans.
A recent study in the Journal of the American Medical Association found that 43% of patients with diabetes and cardiovascular disease received ZERO evidence-based treatments such as statin medications and ACE Inhibitors1.
All of these patients had doctors. It was their doctors who failed to prescribe these medications for their patients with heart diseases.
You do not want plan members to see doctors who neglect to prescribe the treatments that are known to reduce the risk of future heart attacks.
You would be wise to incent your plan members to avoid these doctors and instead see doctors that DO appropriately prescribe treatments that help prevent future heart attacks.
There are specially designated hospitals that treat cancer in America called Comprehensive Cancer Centers. The National Cancer Institute designated these hospitals because they have an approach to patient care that particularly focuses on coordination among the various cancer doctors: medical oncologists, surgical oncologists and radiation oncologists.
This coordination is particularly important because cancer often needs to be treated with a combination of chemotherapy (from the medical oncologist), surgery (from the surgical oncologist) and radiation (from the radiation oncologist).
A 2016 study found that cancer patients ages 22-65 treated at Comprehensive Cancer Centers have better outcomes than those treated at non-Cancer Center hospitals for a variety of cancers including breast cancer and colon cancer—2 of the most common cancers for employer-sponsored health plans2.
For cancer, the choice of doctor is very important. Again, it would be wise to incent employees to see certain cancer doctors over others.
Musculoskeletal health problems such as severe arthritis of the knees, hips and spine are often treated by major surgery. Whether or not a patient needs surgery is highly subjective even among doctors.
The Mayo Clinic itself recommends obtaining a second opinion when considering spine surgery. According to the Mayo Clinic, “Spine surgeons may hold different opinions about when to operate, what type of surgery to perform and whether — for some spine conditions — surgery isn’t warranted at all.”
Given the subjective nature of spine surgery, it is important for health plan members to choose the right doctors.
It would be great if an employer-sponsored health plan specifically incentivizes members to see the right doctors for joint and back care.
Opportunity for Employers
You have a large PPO network with a high degree of quality variability within it.
It would be beneficial if you could optimize that network by financially incentivizing plan members to use the higher-quality providers within that network.
The good news is… there is a way.