Thursday, April 30, 2015

Wishful Ideology About Integrated Delivery Systems

Kaiser Health News has posted a telling interview with former White House health adviser Ezekiel Emanuel MD. In it, Dr. Emanuel repeats a bold prediction about the end of health insurance companies:

Question: You also predict the end of insurance companies as we know them. Rather than continuing to function as the middleman between employers and health care providers, you say insurers may themselves contract with networks of doctors and hospitals, morphing into integrated health care delivery systems. But a one-stop shop isn’t always good for consumers. Networks are restrictive, and at least now, if your insurer turns you down for treatment, your doctor may go to bat for you.

Answer: I don't agree with you. In general, integrated systems do a pretty good job compared to lots of other ways care could be delivered. We like the adversarial system. We believe that’s the best. On the other hand, with integrated networks you can have better coordination of care. And people are mildly sticky. Once you pick an insurance network, you tend to stick with it. That's also good for the insurer. If someone selected you, year in and year out you'll be with them. That changes the dynamic. And to the extent people are long-term keepers, that’s going to be a better arrangement.

"Better arrangement?" The Population Health Blog isn't so sure:

1. As pointed out at the start of the interview, health insurance has been around for more than 200 years. Its staying power is testimony to the enduring value proposition of pooling and monetizing risk. We discard that our peril.

2. Assuming "integrated systems" will competently manage that risk is a stretch.

3. Part of competently managing that risk - even for provider groups - is utilization review.  While the interviewer unflatteringly portrays that as "your insurer turns you down for treatment," the truth is far more complicated mix of advantages and disadvantages that have been heavily regulated (an example here) for decades.

4. Can enlightened "coordination of care" make utilization review unnecessary?  The luxury of Dr. Emanuel's anti-health insurer ideology makes it easy for him to say yes.  So far, inconvenient facts about the ACO pilot program suggest a different story.

5. Plus, can restrictive networks also make utilization review unnecessary?  It remains to be seen whether consumers will appreciate the irony that this invention of managed care is now being embraced by Dr. Emanuel and other progressives, or agree that significant limits on provider choice will be a "better arrangement."

6. Last but not least, doctors like the PHB have been trained and acculturated to put the individual patient's interests before any other consideration, including the success of an integrated delivery system. Unable to say no, our loyalty will translate to the usual specialist referrals, sophisticated testing, the latest technology and the priciest drugs.  Culture trumps everything.

Like it says, the PHB isn't too sure.  Maybe with the right combination of patient incentives, decision support, shared decision making, risk stratification and tailored population health, integrated systems will ultimately prevail.  Time will tell.

Give credit, however, to Dr. Emanuel for being consistent over the last two years.

The same is true for the PHB.  Based on the emerging facts on the ground, the PHB still thinks the odds remain against Dr. Emanuel.

And the offer of a $1000 bet still stands.

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