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Speaker 1: First things first, the professor at quarter to three on day two.
[Laughter]
Speaker 1: I speak in 55 minute blocks.
[Laughter] |
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Speaker 2: You guys are fine, no problem.
[Laughter]
Speaker 2: Teasing aside, I really was struck by the last four presentations and the degree to which if they are in fact, if everybody accomplishes all their goals. We will be about 90% plus on the way towards our goal. I could easily just say, “Hey, do that and we’re set.” But our group tried to step back a little bit and think carefully about this price quality thing. |
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There is a literature out there on literally value equations. That says, “Value is equals price over quality.” We are teasing in our group that that means we have an equation that has three variables in it and all three of them are unknown. We don’t really know very much about price, we don’t know very much about quality, and the absence of those two pieces of information we know by definition nothing about value. |
| 01:13 |
So we are trying, we thought through what kinds of information we have, what kinds of information we could get. Divided the task in to short term and long term kinds of things. And try to focus on in the short term, on the stuff that we think is either already there or very close to being there. With an understanding that we’re not going to have a holy grail of an exact price, and an exact quality indicator down at the disaggregated level that really matters to a consumer. |
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It’s really important, even if we could get a great quality indicator for a hospital and a really clear price for a particular procedure in that particular hospital, most consumers in truth, don’t really care very much even about that because that’s an average. And they don’t really care what that hospital’s average price is. They don’t care what that hospital’s average quality is. They want to know what my price, for my procedure on my doctor if my day, this Wednesday, and they don’t care about the average. |
| 02:27 |
It’s no consolation to the consumer who has a bad medical outcome to say to them, “Yeah, if you went to that hospital, they have a highest average.” You know, if you have a bad outcome, you had a bad outcome. Anyway, so we are struggling with that. |
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In the short term, we think that there are some fairly good price data, better than we thought at the start. Prices, Bob helped and Mike, who is in our group, helped guide us through the reality that there is no such thing as a list price with regards to multiple medical procedure most of the time, especially if they are bundled. It just isn’t out there. |
| 03:08 |
What we do have is what the payers pay. And what the pairs paid is the closest thing to a price we’ve got for the commercial world right now. Where Medicare, we have the coupon rates, for Medicaid, we have what Medicaid is willing to pay. For the uninsured, we basically have charges and that’s all we’ve got. |
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Compounded by some individual provider information at the hospital level about how providers might discount from charges for their uninsured patients, but we’ve got those four from you. So began to think, well if we could put together praise information for those four different categories of patients.
So if you go back to the profile that somebody answers and designed for us, if a patient was Medicare patient, they could know they could begin to instruct pricing around Medicare based on those published grades, and those data exist. If the patient was uninsured, they could get charged there. If the patient was a Medicaid, the patients don’t. |
| 04:11 |
Four major categories with an understanding that the commercial world is really subdivided into this self-paid plans and those that are genuine commercial products. Then we began to think in terms of a specified set of procedures about which we could construct price information for those various categories.
We thought in terms of 8 or 10 or 12 procedures that involve the range of activities. Starting in the end with the price setting moving to admission to a process of care and we have captured a full bundled set of services. I think in an ideal world we thought maybe we could identify the 8 or 10 or 12 such things commonly cheap and get pricing information now for our four main categories of patients. |
| 05:04 |
And we think that that can be accomplished fairly short term. I can’t read these are little things fast because we think most of those data actually exist. In the longer term, on the price thing, what consumers really need is to be able to obtain prospectively what their out of pocket price is going to be. And make judgment calls about how much they are willing to pay for what levels of quality. Getting that anticipatory information on what by individual out of pockets are going to be is a huge challenge. |
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Now with this tool you better have the equation within quality half of the equation. There are bunch of the literature in this area has said, “Price information as a basement for a quality is really hard to get and we ended up risking that.” We decided who’s pretty good to patch a quality information out there and very hard to find price information. |
| 06:04 |
But in terms of the short term quality data that do exist already and are gathered in for and it came at some level include the mortality information, include the hospital quality indicators stuff. With this question of how to unbundle the things mean we are trying to get to have a lot of deposit for the price of an entire episode of care. How we parcel the pieces of quality that go in to the doctor part of that versus the hospital part of that versus the therapist part is not clear to anybody. |
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We do have fairly good patient and member satisfaction data that are gathered into vital plans individually or by hospitals. I was not aware of this, but apparently at the mass level there are emerging physician level measures that are likewise very close to being online and available for selective episodes. |
| 07:04 |
We think, first of all we followed the other groups' chief volunteers, our would be in pretty good shape to establish some of these equations. But the group, and the group that’s made up of Bob and Mike who’s already gone, Brenda back here, Kim, Diane and Cathy joined us for the back half. We struggled with this kind of on going national, if not state levels schizophrenia about how much we actually want to involve ourselves in this price quality equation. Because it implies that some of us sometimes will make accurate decisions to buy cheaper, lower quality health care because that’s what fits our equation at the moment. |
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I think it was Diane who said, “When is my bladder, there is no cheaper option. I am not going to buy the cheaper healthcare, period.” And I can assure you that every October when I have to select my plan, I am not allowed to go home and tell my wife that I’ve put her on the cheap one.
[Laughter] |
| 08:23 |
Speaker 2: One of the fundamental issues in the price quality problem in health and healthcare has historically been that nobody wants to be the K-mart of healthcare and nobody wants to buy their health care at K-mart of healthcare. So we are concerned about that. But we think there are data available that we can translate that data into useful consumer level information in a fairly strict proto-fashion. The resources required and the timelines are actually additional and brilliant resources within AHCA or by sometimes with AHCA.
[Applause] |
| 09:09 |
Speaker 1: Had a question? |
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Audience 1: I have a question, it just dawned on me yesterday, it was said several times and I am in agreement with this, is from my health policy prospective that not the least expensive care is not necessary less quality care. In fact the data problem does not support that. |
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Audience 2: No, I would argue with you whether you’re talking cost or you’re talking about the retail price of that. Yeah, there are some information of it, it’s the fourth that you are in better care may be less expensive, but you have to have a margin to reinvest into the assets. |
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Audience 1: And the other thing is when the founders of NCA came out or national they go or internationally, their goal actually stated was to be the Wal-Mart of healthcare. And if you look in Florida, at the top 100 hospitals in Florida, many of them are in NCA kind of has to d with their pension details and pension healthcare delivery.
Their attention to not implicating things and customer service and part of their success is that when they go into the pairs, they come in a lower price. So they have actually not break down being a Wal-Mart, which I have always found to be interesting. Because I would have said at a mass that sort of guys love that effort and I would have said, “There you go, you always have good outcome..." |
| 10:44 |
Speaker 2: There is big literature on the proposition of quality can cost less. It doesn’t mean it’s always priced lower. And that also includes a lot of cost that most individual consumers don’t include in their immediate decision to go to the doctor for moral. It’s in a long term cost, work loss cost, time cost, and all of those things that are much, much harder to measure. But your point is well taken. The relationship between price and cost or between price and quality does not mean in a linear way |
| 11:19 |
Audience 2: I think the other thing that is worth kept saying - and it goes back to the articles that we were sent on this issue of consumer reasoning transparency. In general is that if you can provide ratings or qualifications or report cards or some kind of scoring on the entire episode of care or all the pieces that in to that as well and price information - have whether that is what you are paying or not. At least it starts to educate the consumer about the relativity that is healthcare and about this notion that in fact somebody pays and it costs something to produce.
I mean there’s some educational value in just informing the public about that much because frankly the norm is, many people believe that those things have no relationship to one another. And that I can walk in to the hospital emergency room only when I absolutely have to be there and while walk out without putting down 50¢ of my own money. |
| 12:29 |
So I think that if nothing else being able to have and display and did present and disseminate and encourage the public to know these things, can’t help but improve the system overall. Whether people use it their own self when it’s their own surgery is less relevant to me than the fact that its made available on an off chance that they want to use it or that it educates them about the fact that we do know this things. Continue to protect if you don’t know the answer I think is untenable and frankly deceptive. |
| 13:12 |
Speaker 1: I hear over and over and I think its absolutely half of the equation that people want to know how much is coming out of my pocket or something. |
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Speaker 2: Absolutely. |
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Speaker 1: The other half of the equation is, they want to know how much that will they be next year. And when they can look and see that it’s for a cost they are paying half a mile away, they get that that translates perfectly. That’s what gets them. I am not telling you 100% get part, but I’m telling you where we have done education work, we see direct connects of people choosing to go to the place that we pay less over the place that we pay more, even if its no different to them at all. |
| 14:02 |
Speaker 2: I understand that. The other comment I would like to add about this is that in Florida at the Commonwealth Fund reminded us, not very gently over the last few days, but we’ve got a three plus million people problem called the uninsured. And Bob was particularly eloquent in pointing out that those are the people who, if they are poor and uninsured, which is overwhelmingly the mode of category, are not making price differentiable decisions because it doesn’t matter. |
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If they are wealthy uninsured, which are few and far between, I suspect they are not taking price differentiating decision valuable because they value about care. They will write a check no matter what it would sell. Handling how price and quality impact in the world of the uninsured has been a category and as a category of folks who still don’t know about... |
| 15:05 |
Audience 2: I just have one final clarification. In what entity wants to be the Wal-Mart of health care? |
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Audience 1: NCA. |
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Audience 2: Is that what the payers see as the cheapest rates in healthcare at NCA? |
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Speaker 1: What? |
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Audience 2: How many times as they go out do they say the goal is to be the Wal-Mart of healthcare? Are these the lowest rates? |
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Audience 1: It was Humana back in the days when the two big hospital chains merged in NCA and now its Humana we are going for the mass market. |
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Speaker 1: But NCA is clearly normal it’s just that other people pay for may have different views, but when you have a lot of competitive environment at NCA, it is accurate that the are among the lowest order in charges. Where you have lower complication they own the highest in the state. |
| 16:08 |
Audience 1: I may have said NCA, and I can reiterate. When I lived in Tampa, I remember a couple of weeks ago, they are really with the model line and what they charging the third parties and they try to get more patients to render their services and they are pretty a good job. |
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Speaker 1: So we have one more, but them since HCA is not here I don’t want to |
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Audience 2: Yes they are. |
