A Call to Action
We, the Board of Directors of America's Agenda: Health Care for All, as leaders and representatives of international and local unions, business and healthcare provider organizations, call on employer and union sponsors of self-funded, employment-based health plans to join us in a collaborative effort to transform the way health care is delivered to our plan participants.
This call to action is an invitation to share knowledge and experience and, where appropriate, take joint action. Our objectives are to drive continuous improvement in the quality of our members' care, improve their health outcomes, and generate substantial health cost savings.
"... join us in a collaborative effort to transform the way health care is delivered ..."
Douglas H. Dority
President & Chairman
United Food & Commercial
Joseph J. Hunt
Communications Workers of America
R. Thomas Buffenbarger
International Assoc. of Machinists and Aerospace Workers (IAM)
Bricklayers and Allied Craftworkers
A. Philip Randolph Institute
Joseph R. Bock
Florio, Perrucci, Steinhardt & Fader, LLC
United Mine Workers of America
President Office and Professional Employees International Union (OPEIU)
UFCW 8 - Golden State
Jeffrey A. Bond
SVP, State Advocacy
James P. Hoffa
International Brotherhood of Teamsters
Bernard J. Tyson
Chairman & CEO
International Alliance of Theatrical Stage Employees (IA)
Edward M. Smith
Union Labor Life Insurance Company
Terence M. O'Sullivan
Laborers' International Union of North America
The Honorable Richard A. Gephardt
Former Majority Leader
US House of Representatives
Edward J. McElroy
American Federation of Teachers
George Donald W. Bohn
Vice President, US Government
Affairs Johnson & Johnson
SVP for Government Relations
Dr. Samuel R. Nussbaum, MD
Executive Vice President,
Clinical Health Policy
Chief Medical Officer, WellPoint, Inc.
Dr. Janis DiMonaco
New Jersey Education Association
United Food & Commercial Workers (UFCW)
The Patient Protection and Affordable Care Act (ACA) expands healthcare coverage to millions of deserving Americans, but the federal reform law lacks a coherent strategy for reigning in relentless growth in health costs that makes our care increasingly less affordable. There is little serious expectation that the ACA will solve the ongoing health cost crisis—a crisis that has wiped out real income gains for the average US family over the last decade.1
"In the current health care environment, self-funded, employment-based health plans ... are uniquely positioned to lead America by example, right now ..."
Seven out of 10 CFOs ranked rising health care costs as a top concern for their businesses in 2013.2 Rising at annual rates 2 to 5 times faster than general inflation,3 the cost of health care continues to consume ever-larger proportions of private and public resources needed to invest in pressing economic needs like infrastructure improvement, education, and job creation.
Fortunately, American businesses and unions don't need to wait for a national political consensus or a new reform law to address the root causes of spiraling health costs. In the current health care environment, self-funded, employment-based health plans—employer-sponsored, union-sponsored, and jointly-governed Taft-Hartley health and welfare plans—are uniquely positioned to lead America by example, right now, by taking action to deliver higher quality, more affordable healthcare to the workers and families they serve.
One-third of Americans working in the private and public sectors are enrolled in employment-based, self-funded health plans.4 Acting alone or in concert, self-funded health plans have the scale, administrative flexibility, and market power to require that care be reengineered in specific ways that optimize care coordination, reduce waste, and align provider, payer, and patient incentives to deliver evidence-based, best-quality care at the right time and in the lowest cost setting to each of their plan members. A handful of self-funded plans have actually done so.
The rewards for doing so are high. Studies show as much as half of annual US health care spending adds zero value.5 With the total health care expenditures at about $3.1 trillion this year6, potential savings from elimination of redundant, inefficient, or inappropriate care are staggering.
Employers and workers who pay so dearly for health care have much to gain from demanding real value for the dollars they spend!
12 Design Principles
Redesigning Health Care Delivery
for the 21st Century
The evidence is compelling. Adoption of the following high-value care delivery principles will enable our health plans to achieve these objectives:
- Strengthen advanced, patient-centered primary care as the center of overall care coordination — Team-based, advanced primary care practices must be the hubs of virtually- (or vertically-) integrated, high-value care networks. Care coordination should extend across primary, specialist, hospital, and home settings, as well as through transitions between care settings.
- Assign personal responsibility and accountability to individual primary care providers for supporting patient compliance with personal care plans, including medication management and care delivery coordination — Individualized patient care plans should reflect evidence-based clinical recommendations with consideration given to patient lifestyles and preferences.
- Replace self-funded health plan fee-for-service reimbursement to primary care practices with per-patient fees for providing optimized primary care, medication management, and coordination of overall care.
- Advanced primary care practices working in partnership with self-funded health plans should compensate individual primary care physicians (or where appropriate, nurse practitioners) with competitive salaries and incentives to attain high standards of patient care quality and patient satisfaction — The self-funded health plan should routinely assess health outcomes of its patient population and satisfaction of its members with their care. The practice should use the same assessments for allocation of physician (or where appropriate, nurse practitioner) incentive awards.
- Expand and optimize the scope of team-based, primary care — Primary care physicians should provide care at the "top of their licenses," which is to say, primary care providers and allied health professionals working under their direction should offer an expanded scope of primary care services that are frequently not provided at all or are provided by specialists at substantially higher cost, without demonstrable improvement in care quality, in a conventional fee-for-service environment.
- Expand convenient patient access to optimized primary care — Guarantee same day or next day acute care appointments with the patient's personal primary care provider and ongoing direct access to personal primary care physicians via remote communications (telephone, email, online patient medical record account, etc.). Locate primary care centers at or near workplaces and in communities where employee families live.
- Minimize or eliminate patient cost-sharing for primary care — Elimination of financial barriers will increase demand for primary care in lieu of unnecessary utilization of emergency room care and other higher cost care settings.
- Identify a self-funded plan preferred referral network of high value specialists and hospital centers of excellence — The plan's advanced primary care practice(s) can be a source of key information on patient satisfaction with specialists and hospitals and those providers' willingness to cooperate with the plan's primary care physicians. The self-funded health plan's ASO network provider can be a key source of information on hospital and specialist care quality and costs.
- Preserve employee/patient choice of access to downstream care; No gatekeeping — Although self-funded health plans may adopt value-based cost-sharing and other financial incentives for plan participants to select high-value providers in the health plan's preferred referral network, patients should retain the option of accessing downstream specialist or hospital care without referral or prior authorization of the primary care provider.
- Assure that primary care providers' clinical care decisions are made in the best interest of patients, based on clinical evidence with consideration given to individual patient preferences, and independent of organizational financial interests.
- Adopt advanced primary care models that are rapidly scalable.
- Assure that integration of real world, evidence-based clinical knowledge and its applications are continuously up-to-date so that care remains optimal for patients..
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1 D. Auerbacj and A Kellerman, "A Decade Of Health Care Cost Growth Has Wiped Out Real Income Gains For An Average US Family," Health Affairs, http://content.healthaffairs.org/content/30/9/1630.abstract
2 Tim Mullaney, "Survey finds health care costs top CFOs' worries," USA Today, September 23, 2013, http://www.usatoday.com/story/money/business/2013/07/23/cfo-outlook-bank-of-america-survey/2578423/
3 Kaoser Family Foundation and HRET, Employer Health Benefits Survey (release slides), August 20, 2013, http://kaiserfamilyfoundation.files.wordpress.com/2013/08/8465-employer-health-benefits-2013-chartpack.pdf
4 calculated from data reported in Employer Health Benefits Survey (Endnote 1), http://kff.org/private-insurance/report/2013-employer-health-benefits/?special=footnotes#footnote-sum1, and Robert Pear, "Some Employers Could Drop Out of Insurance Market," New York Times, February, 17, 2013, http://www.nytimes.com/2013/02/18/us/allure-of-self-insurance-draws-concern-over-costs.html?_r=1&
5 PricewaterhouseCoopers' Health Research Institute, The Price of Excess: Identifying Waste in Health Care Spending, http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml
6 Report of CMS Office of the Actuary, reported in "National Health Expenditure Projections, 2012–22: Slow Growth Until Coverage Expands And Economy Improves," Health Affairs, http://content.healthaffairs.org/content/early/2013/09/13/hlthaff.2013.0721