James Mandell and Edward J. Benz Jr.

A threat to quality in health care

By James Mandell and Edward J. Benz Jr.
July 16, 2011

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AS THE state wrestles with the enormous challenge of trying to control health care costs, the concepts of limited and tiered insurer networks have taken on a new currency. Shunned in practice only a few years ago, they are now being touted as a way to make consumers more price conscious and encourage providers to reduce costs.

Limited and tiered networks work by excluding so-called high-cost providers from certain insurance plans or by shifting more of the costs of health care onto consumers through higher deductibles and/or co-pays for choosing these hospitals.

In theory, they create incentives for hospitals to deliver high-quality care at the lowest cost, but in reality, quality and the unique needs of patients requiring specialized care are all but ignored in these insurance products. If not properly structured or regulated, they could create serious barriers to critical care. As insurers implement such networks, they should include the full range of highly specialized care required by patients with the most complex medical conditions. Nobody can anticipate if and when they or their child will need advanced care.

We must also guard against tiered and limited networks contributing to disparities in access to health care - disparities that the health care community and public officials have worked hard to eliminate. The additional deductibles and co-pays to see certain providers imposed by tiered networks will hit low-income individuals and families hard, and may create fundamental access barriers. As an indication of how this works in practice, one of the major insurers has placed over half of the pediatric hospital beds in the state in its higher-priced tier, including all beds in major facilities west of Boston.

There is also a danger that the shift to more restricted networks will disrupt existing treatment plans and patient-physician relationships. Recently, 125 patients at Dana-Farber Cancer Institute were put in a terrible position when their health plan removed Dana-Farber from its network. The rules around whether and how these patients can continue treatment at Dana-Farber are confusing to both patients and their oncologists, and trying to determine if they should change plans, switch physicians, or apply for extensions only adds uncertainty and anxiety to their already stressful situation. When these network products emphasize price over quality, patients with complex conditions may wind up receiving less than optimal care, and overall costs may be lower if the patients are cared for by the most experienced provider in the first place.

Highly specialized hospitals drive much of the innovation in health care, and innovation is essential for pushing costs down. A program developed at Dana-Farber/Children’s Hospital Cancer Center enables children being treated with chemotherapy to receive IV hydration at home. Since 2007, the program has eliminated more than 700 overnight hospital stays, saving more than $900,000 and granting sick children precious time at home. Additionally, clinical trials define the next standard of care as we advance cancer care. But how patients will be allowed to join clinical trials under select or tiered networks is unclear, raising concerns that reduced participation could eventually slow the pace of discovery.

As we work to reduce the cost of care via the use of networks, the state should insist that:

■There be absolute clarity about what consumers and employers are buying (and not buying) when they select limited or tiered network plans;

■Changes in networks not disrupt the continuity of care for patients;

■There be a fixed cost ceiling for patients with highly complex medical needs that guarantees access to the right care.

Massachusetts will continue to lead the nation in health care reform only if it strikes the right balance between cost and quality.

Dr. James Mandell is chief executive officer of Children’s Hospital Boston. Dr. Edward J. Benz Jr. is president and chief executive officer of Dana-Farber Cancer Institute.