The Collaborative Forum

I’ve been in the healthcare field for over 20 years now, and I still believe that the vast majority of those involved—whether on the payer or provider side—truly want what’s best for their patients or members.  After all, healthcare quality and cost affects everyone.

In an editorial published earlier this week in the New York Times entitled “The Gaming Begins,” the editors point out the difficult struggle over how to calculate medical loss ratio under the new healthcare law and discussed concerns that insurers could “game” medical loss ratio by spending money on administrative costs, rather than on meaningful measures to improve quality.

Beginning in 2011, the new law requires health insurers to spend 80-85 percent of the premiums they collect on medical services or activities that improve the quality of care (the medical loss ratio).  Insurers can then use the remainder of the premiums for things such as marketing, overhead, salaries, and profit.

The editorial accuses some insurers of overreaching, noting that the National Association of Insurance Commissioners is being lobbied by some insurers to adopt a broad definition for what constitutes quality improvement activity, while consumer advocates hope to keep the definition narrow.

We at Pharos work with both payers and providers, and interact daily with consumers.  We have always felt that our partners have turned to us because they share our goal: to provide better care, while reducing costs through lower admission and readmission rates. Clearly our payer and provider partners as well as the consumer see the benefit; and when improvements in care lead to improvements in cost and quality, who loses?   No one!

Toward the conclusion of the editorial it reads:

Sensible boundaries can surely be drawn. Health information technology that improves patient care by preventing drug interactions should clearly count…Programs that help manage and coordinate the care given chronically ill patients should count…

We’re encouraged that the New York Times views favorably what we set out to do 16 years ago: use information technologies and care coordination to impact quality and cost for chronically ill patients. How do you view the MLR debate?