Health care Quality: Different Meaning For Care Vs. Coverage

By:  Cynthia Marcotte Stamer, Publisher, Solutions Law Press, Inc.; Executive Director, PROJECT COPE:  Coalition on Patient Empowerment & Coalition for Responsible Healthcare Policy

American patients and their families need to be careful about mindlessly making health care choices for themselves or their family in reliance on healthcare “quality” data or guidance by private health plans and insurers, Medicare, Medicaid, or other government payers, and other public and private entities that allow the cost of care to shade their valuation of the quality of care.

The value of quality data – regardless of its source – in determining the quality and value of a proposed plan of care inherently depends upon how well a patient’s actual circumstance fits the assumptions upon which the quality analysis and conclusions rest.  Different treatment plans often impact differently patients diagnosed with the same condition for a variety of reasons.

Patients and their families making health care decisions for themselves or a loved one generally should use a two step approach when making health care provider or treatment decisions:

Patients and their families attempting to make decisions about the treatment plan for a patient affiliated with a life threatening or major chronic illness rightly should work with their health care provider to critically evaluate the options based first solely on the particular needs of the patient first without regard to cost, and then separately evaluate how cost barriers to securing the best treatment for the patient may require compromises or other tradeoffs.

When working with physicians and other health care providers, patients and their families need to understand the role and proper use of quality data – whether used by health care providers to determine care pathways, medical peer review, licensing boards or other quality assurance agencies enforcing quality standards for health care providers, or payers like Medicare, Medicaid, or other government payers or private insurers, self-insured health plans or other nongovernmental payers.

Because each patient’s medical and other circumstances are unique, very few patients fit cleaning the assumptions built into the clinical or payment pathways used to determine quality for a cost or medical efficacy determination.  In essence, each patient considered individually is an outlier at some level.  While these individual deviations have little material effect on the efficacy of proposed treatments in some instances, disregard of unique characteristics of the physical, emotional, psychosocial or other status of the patient significantly undermines or changes the likely efficacy of treatment. The assessment of the care and treatment needs and options of a patient without regard to cost inherently allows the patient, his family and his treatment team to evaluate the best interests of the patient, taking into account the unique physical, emotional, psychosocial and other realities of that patient.

Because the appropriateness of a proposed treatment plan inherently depends upon how closely the patient’s situation fits the underlying assumptions upon which the conclusions drawn from the quality data rests, patients and their families first should investigate and evaluate the needs of the patient and the care options available for treatment from a purely health care perspective without regard to cost based on the unique situation of that patient.   Review of these assumptions with the patient’s physician and other health care team helps determine not only whether the “standard” treatment fits the patient, but also what the patient and his caregivers need to be prepared to deal with the realize the benefits of the treatment proscribed and the likely effects of compromise or deviation from those expectations.  This analysis not only helps ensure the effectiveness of the plan of treatment but also reduces the risk that the patient will be hurt or his care or recovery undermined by the administration of a treatment plan that doesn’t fit the patient or performances that the patient or those supporting him in his care cannot reliably deliver.

Just as patients and their families should carefully question and evaluate assumptions underlying the quality and efficacy data behind treatment recommendations made by health care providers for the treatment of the patient, they also must carefully evaluate the health care “quality” determinations and decisions made by the public or private health plan that covers the patient.  Patients and families need to resist the urge to mindlessly accept without question the increasingly common practice by of private insurers and Medicare and other government regulators of accusing or suggesting that physicians or other health care providers are engaged in overprescribing, “fraud” or other bad medicine because the health care provider prescribes or delivers care supported by the medical quality literature in light of the needs of the patient which exceeds or deviates from the generic, one size fits all care plan selected by a payer to fit the cost containment goals of the payer.

Patients and their families need to understand that quality decisions by public or private payers for purposes of deciding what and how much treatment a payer will pay for inevitably both minimize the importance of the unique needs of the patient and adjust their notions of quality to fit the budget and profitability standards the of the payer based on the premiums or taxes the payer collects to fund the promised benefits.  These are statistical actuarial questions targeted on the amount of dollars that the payer is willing to spend for the dollars collected.  It is not unusual for a government payer such as Medicare or a private payer to try to limit the care that the insurer pays for to care that is less expensive without regards to the unique needs of a particular patient.  The outlier needs of particular patients have little value and receive little or no consideration in this analysis generally.  Consequently, it is not unusual for a Medicare, Medicaid, a private insurer or health plan or other payer to decline or resist paying for certain treatments that a physician orders in an effort to tailor care to the unique needs of a patient when the needs of the patient don’t fit the assumptions underlying the coverage design of the payer.

At the end of the day, patients and their families concerned about getting the best outcome for the patient should inform themselves and actively work with their physician and other health care providers, their health plans and other sources to familiarize themselves not only with the treatment needs and options of the patient, as well as the underlying assumptions behind the quality and efficacy findings underlying these treatment options.  By evaluating the assumptions required to achieve the reported treatment efficacy, patients and their providers can promote better care decisions and outcomes by helping their provider to anticipate and address the unique care needs of the patient, can better determine when and if to make tradeoffs in care for health care coverage or other cost or nonmedical reasons and can help improve the effectiveness of the care plan by better anticipating and arranging to meet the assumptions required to support the optimal outcome.

About Project COPE: The Coalition On Patient Empowerment &  Coalition on Responsible Health Policy

Do you have ideas about how to improve the understandability of medication warnings or research findings for patients or other ideas about how to improve healthcare or health care policy?  Share your ideas in the  PROJECT COPE: Coalition On Patient Empowerment LinkedIn Group.  If you have knowledge, experience or other resources that could help patients, families, communities, or the government better understand or cope with  Asperger’s or other health care conditions, costs of care, or other challenges affecting Americans and the American health care system, we encourage you to get involved and share your insights.

As American leaders continue to struggle to deal with these and other mounting problems impacting the U.S. health care system, the input of individual Americans and businesses and community leaders is more critical than ever.  Get involved in helping to shape improvements and solutions to the U.S. health care system and the Americans it cares for by sharing your ideas and input through the Coalition For Responsible Health Care Policy  and exchanging information and ideas for helping American families deal with their family member’s illnesses, disabilities and other healthcare challenges through PROJECT COPE: Coalition On Patient Empowerment.

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of PROJECT COPE.

The Coalition and its PROJECT COPE arise and run on the belief that health care reform and policy must be patient centric and patient empowering.  The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Step up and help bridge the gap when you or your organization can. Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining PROJECT COPE: Coalition On Patient Empowerment and by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

You also may be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, and/or our HR & Benefits Update electronic publication available here.

You also can get details about how to arrange for your employees or other communities to participate in training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here.

NOTE:  This article is provided for educational purposes.  It is does not provide legal advice, establish any attorney-client relationship or provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.  ©2016 Cynthia Marcotte Stamer, P.C. Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.