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How to find quality healthcare

Jim Mueller - Mueller QAAS
Jim is the founder, President, and CEO of Mueller QAAS, LLC, an independent healthcare consulting firm located in Waukesha, Wisconsin. Jim provides leadership and strategic direction to Mueller QAAS, and also provides his clients with objective market insight on their employee benefit decisions.

When you think about the problems facing the U.S. healthcare system, the first thing that comes to mind is probably cost. The issue of quality, or what we get for these expenditures, is usually a secondary concern, unless you or a family member are undergoing treatment. Even so, I believe that promoting the use of high-quality providers is key to solving the problem of high health costs.

In a free market, higher-quality goods and services generally cost more than those of lesser quality. This is not always the case in healthcare because of how prices are negotiated between healthcare providers and payers. Historically, providers are paid according to the services they perform, regardless of how well they perform the service.

When costs are not aligned with value, low-quality care can actually cost more than high-quality care. Repeat surgeries, hospital readmissions, and other unnecessary treatments increase utilization and costs. In addition, healthcare providers’ top management is paid primarily on top- and bottom-line growth, with little to no incentives for quality outcomes or safety. In fact, administrators’ financial incentives are almost always based on volume of services and the profit margins of their various “lines of business.” Orthopedics and cancer care are both high margin.

When facing these sorts of life-altering diagnoses, everyone would like to find the doctor who will deliver the best chance at the best outcome, but this is easier said than done. In most fields, performance is demonstrated through results. In healthcare, however, outcomes don’t always tell the whole story because genetics, behavior, and environment influence outcomes long before a doctor intervenes. And while customer satisfaction may be a valuable metric when buying a car or cellphone, it’s of questionable use in healthcare. Few patients are medical experts, and the friendliest doctors are not always the best.

This is why it is so important that patients have access to objective information on healthcare provider quality. Many resources claim to provide this, from annual “best of” lists to countless websites and mobile apps, yet it’s not always clear to the consumer which of these they should trust. One problem with health transparency startups is that they are often limited by the need to purchase healthcare data. Insurance companies and certain nonprofits do not face this challenge because they already have access to vast amounts of claims data from a wide range of providers.

Recently, some of the larger carriers have begun sharing their provider-quality data with their members. For example, UnitedHealthcare has a program that evaluates providers for providing quality and cost-efficient care, and provides this information to members through the online provider search tool. Some UnitedHealth insurance plans reward members with lower copays when they choose a provider who has been found to practice evidence-based medicine and follow medical society and national standards.

Similarly, Anthem can provide its members with information on clinical quality and cost through the provider finder in the Anthem Engage mobile application. High-scoring physicians appear at the top of the search results, making it easier for patients to find them. And for specialty care, like spine surgery and cardiac care, Anthem’s facility search tool shows which medical centers have been recognized as centers of excellence by independent medical organizations and experts.

Even if you are not a member of one of these two large insurance companies, you can get objective healthcare-quality data from the Wisconsin Health Information Organization (WHIO). WHIO is a non-profit that operates the nation’s only statewide voluntary all-payer claims database in the nation. High-level quality scores are available through WHIO’s website, which grade facilities for providing recommended care at the right time and making good use of your healthcare dollars.

WHIO also sells access to results from its Datamart, which goes to the provider and procedure level. This data is not easily digested by the average consumer and is typically used by those in the healthcare industry in contract negotiations. I make the data I purchase from WHIO available to my clients because I believe they deserve all the help they can get to find quality healthcare.

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