Getting More Value for Your Health Care Dollar

tt104-v3.jpgWhether as a child, a teenager, or an adult, we have all sustained an injury or illness.  It’s just a part of life.  Sometimes these things are minor in nature; other times they are much more serious.  When the serious times arrive, many of us are fortunate enough to secure quality health care services that we can afford.  But for thousands of people across New Jersey, quality affordable health care remains elusive. It is something we as a state and as a nation can no longer tolerate.

In 2010, President Obama sought to tackle this issue head on through the Affordable Care Act (ACA).  While Congress continues to bicker over a law that is now six years old, the rest of the country has moved on because they have seen the benefits firsthand.  Over 20 million Americans are now insured thanks to “Obamacare.” That is not a matter of public opinion, but a matter of public record. Moreover, the ACA has done more than just provide insurance to those in need: it has changed the conversation on how health insurance is provided.
 
Nowhere is this discussion more important than in New Jersey.  Our state is an amazing place that we are all proud to call home, but it is not without its faults.  One of them is the manner in which health care services are delivered.  For decades, New Jersey has maintained a system that was based on the number of patients doctors and hospitals were able to see.  It incentivized conducting more tests and procedures, as opposed to keeping patients healthy.
 
This system, known as “fee-for-service” hasn’t worked for patients or for health care providers.  Patients had to suffer through high premiums, while doctors were forced to see more patients but spend less quality time with them.  All of this has resulted in New Jersey having the second highest health care costs in the country.
 
The ACA, however, is pushing states away from this method.  Instead, it is encouraging a system known as value-based or patient-centered care. Under this kind of system, incentives are given to doctors who work collaboratively with patients and providers to determine what is best for the patient.  The focus is on keeping people healthy, not on simply conducting more tests.  As a result, health care premiums go down.

I have embraced this approach to bringing down health care costs here in New Jersey. A318 would establish the patient-centered medical home program in our state. The purpose of this proposal is to enhance care coordination and promote high-quality, cost-effective care through patient-centered medical homes by engaging patients and their primary care providers. Patient-centered medical homes offer a model of primary care that may attract new providers to New Jersey because the model is effective, sustainable, replicable in small communities, and provides a process to achieve higher quality health care for patients and a way to help slow the continuing escalation of health care costs as well as improve health outcomes for New Jersey residents.

That said, we continue to struggle in New Jersey with rising health insurance premiums and deductibles that are becoming unaffordable to the consumer. That is why innovation and an aggressive recalibration of the health care marketplace are needed.  Patient-centered medical homes, accountable care organizations and value-based reimbursement systems are all vital components of driving down health care costs and expanding access.

In 2014 for instance, our state’s largest health insurer, Horizon Blue Cross Blue Shield of New Jersey, partnered with 51 specialists to improve patients’ outcomes, reduce readmissions, and lower the cost of health care.  This effort led to reductions in readmissions: 100 percent fewer for knee arthroscopy, 37 percent fewer for hip replacement, 22 percent fewer for knee replacement, and a 32 percent reduction in unnecessary C-section deliveries. Not only that, but these reduced admissions meant over $3 million in savings that could then be passed back to the consumers.
 
And, in 2015 Horizon, Aetna and several other health insurance providers announced they would expand their value-based care programs.  For example, Horizon’s OMNIA plans utilize the value-based care system and have been on the market since the beginning of 2016.  Recently, media reports announced that 234,000 individuals had signed up for OMNIA in the first few months.  But perhaps most significant, over 41,000 of these individuals were previously without health care! This is directly linked to the concept of value-based health care and the ability of tiered health insurance plans to control costs without compromising quality of care.
 
Unfortunately, there have been efforts of late to try and stop the progress made by value-based care plans. That is why, I introduced A3266 which provides that a contract between a participating health care provider and a carrier which offers a managed care plan shall not contain any provision, commonly referred to as an “anti-tiering clause,” that prohibits or limits a carrier’s right to use a tiered-network plan in which health care providers are tiered and cost sharing for covered persons is determined by the tier placement of the provider. While transparency and patient accountability are essential in the development of tiered networks, calls to prohibit their use will only stymie the progress made towards more affordable and accessible health care.  
 
Many of us are fortunate enough to have access to quality, affordable health care.  But for too many others, this still remains elusive.  All of us should have that access.  We are the wealthiest nation in the world.  That means everyone should be able to go about their daily lives without fear that the next injury or illness could bankrupt them.  The ACA and innovative payment models, like Horizon’s OMNIA or Aetna’s Liberty Plan, have moved to do just that. That’s my take. What’s yours?


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