Turning Knowledge into Action
How do you want to use hospital pricing data to get better value for your health care dollar? This section of the Employer Price Transparency Project website will empower you to translate data from the Employer Price Transparency Studies and Sage Transparency into action.
The Employer Price Transparency Studies pair pricing data with Medicare Stars quality ratings, but there are limitations on the insights that purchasers – especially commercial purchasers – can glean from Medicare data. But if not Medicare Stars data, then what?
These resources examine sources of quality data, their strengths and limitations, and offer guidance on how to pick the right measures to assess hospital value, providing a more comprehensive picture of health care in your market.
Which quality measures should you examine?
Most quality measures in wide use today are the ones easiest to measure, but they often reveal little variation in performance across providers. Moreover, these “easy-to-measure” metrics usually focus on processes (did the provider do the thing that they were supposed to do?) rather than outcomes (did the patient’s health actually improve?). The resources in this section offer a primer on quality measures: what matters, what doesn’t, and how to use quality data to assess the value of providers in your network.
October 30, 2015
Catalyst for Payment Reform
Virtual summit discussing CPR’s Employer-Purchaser Guide to Quality Measure Selection, which helps purchasers more effectively design, implement and evaluate health care delivery and payment reform programs.
August 31, 2018
Catalyst for Payment Reform
This action brief provides a summary of CPR’s selected “Quality Measures that Matter,” and describes the actions a purchaser should take to utilize quality measurement in their health care decision-making.
What are sources of quality information?
Unfortunately, there is no single authority on quality measurement; multiple resources (free and for purchase) offer conflicting views on the performance of a given health care provider. How can a purchaser sort through the various sources of provider quality ratings? Information in this section provides an overview of the different suppliers of provider quality ratings, examines how and why they differ, and can help guide you to the right resource for your organization.
June 27, 2020
The Robert Wood Johnson Foundation
This free suite of tools is intended to assist purchasers in creating health care quality measure sets. Users can filter through over 700 measures, and receive an alignment score for the measure set under consideration.
June 27, 2020
Employers’ Forum of Indiana
This research brief describes five categories of quality measures, offers a framework for mapping quality measures to measurement purpose, and analyzes sources of hospital quality ratings.
The brief is accompanied by an index of quality data sources, which catalogs whether each source is free or for purchase, which providers and populations it evaluates, the measures it includes and the methodology it uses, along with the nature of the data.
Not every solution is viable in every market; that’s why this section includes materials to help you understand the forces that shape your market, and provides tools and resources to help you optimize the best-fit solution for your organization.
Understanding market dynamics
January 18, 2017
Catalyst for Payment Reform
In the wake of system-wide payment and delivery reforms, the health care ecosystem has grown in complexity, causing health care stakeholders to expand and evolve in response. Listen to CPR’s Suzanne Delbanco provide an overview of the key players in health care, the issue of market power and consolidation among plans and providers, and potential remedial solutions.
June 27, 2020
Catalyst for Payment Reform
This portfolio of resources is designed to help purchasers understand how the structure and characteristics of the market and stakeholders can significatly impact the options for and success of reform measures.
June 27, 2020
Catalyst for Payment Reform
Learn how CPR uses its Market Assessment Tool to to determine market typology and the distribution of power within the market, and to identify which reforms have the highest probability of improving quality and affordability.
Looking for more information about your market?
- The Decision Resource Group’s Market Access Reports provide detailed MSA-level reporting on provider and health plan market share, political forces driving the market’s legislative agenda, and which stakeholders hold the most influence in shaping market dynamics (subscription required).
- Modern Healthcare Metrics, a joint venture between Modern Healthcare Magazine and Healthcare Management Partners, uses Healthcare Cost Report Information System (HCRIS) data to create an electronic database of over 5,000 healthcare facilities’ financial and quality performance.
- Allan Baumgarten Consulting is an independent consultant studying trends, competition and organizations in local health markets. His 11 state market reviews provide competitive analysis of health plans and hospital systems including market share and enrollment trends, financial results and utilization measures. Reports provide additional context through analysis of market developments and policy initiatives in each local market.
Armed with information about hospital prices, hospital quality, and the forces that shape health care in your market, the next step is to determine how to guide members to the highest value care. This section of the site offers a portfolio of strategies in benefit design, network strategy and provider contracting, with resources and case studies to serve as a blue print for successful implementation.
BENEFIT DESIGN
Benefit design strategies create incentives for plan members to select high-value care. Especially when paired with payment incentives for providers, benefit design strategies can pressure providers to accept greater accountability for care outcomes to offer services at a market-competitive price.
Reference-based pricing
Reference-based pricing (RBP) establishes a standard benchmark price – usually set at a multiple of Medicare pricing or at the market average – that a purchaser will pay for specific health care. If a plan member selects a provider whose cost is above the reference price, the plan member is liable to pay the difference out of pocket. Reference pricing is an incentive strategy designed to activate patients to become engaged health care consumers, but can also create incentives for providers to lower their prices.
The market today appears to be divided between two RBP models; large national health plans piloted RBP benefit designs for selected non-emergent, shoppable procedures with high price variation, such as joint replacement surgery or lab services. More recently, new alternative third-party administrator (TPA) plans have emerged who offer RBP benefit design for a variety of non-emergent procedures. These TPAs do not contract directly with providers – they instead have blanket policies of paying providers rates of Medicare + X%, and then offering transparency tools and advocacy support to guide plan members to low-cost providers, and negotiate with health systems to bring their prices down to the reference price point. The resources that follow are centered on the first approach.
December 1, 2017
Catalyst for Payment Reform
Catalyst for Payment Reform provides an overview of Reference-based Pricing: how it works and what it does. The action brief also profiles purchasers who have implemented reference pricing and the outcomes they achieved.
April 1, 2016
The Urban Institute
In this report, the Urban Institute takes a deeper dive into Reference-Based Pricing (RBP). The report summarizes the strengths and weaknesses of the RBP model and describes core design features required for program success.
Health Affairs
Learn how the California Public Employees’ Retirement System (CalPERS) dramatically reduced the total spending and price of certain health care procedures, without measureable differences in quality outcomes, by implementing reference-based pricing.
June 1, 2018
Catalyst for Payment Reform
Learn about the RBP program The Home Depot, Inc. implemented to address price variation and unnecessary spending. This case study reviews their strategic approach to selecting services and pricing, and their focus on employee communications to ensure smooth implementation.
Download the case study (requires free account)
Centers of excellence
June 27, 2020
The Urban Institute
The Urban Institute provides an overview of COE program mechanics; the report summarizes the model’s strengths and limitations, and recommends design choices to mitigate against potential pitfalls.
June 4, 2018
Catalyst for Payment Reform
Learn about Walmart, Inc.’s 2013 centers of excellence (COE) program for spine surgery to address variation in quality of care and inappropriate care. This case study details Walmart’s strategies for COE program design, choosing partners, implementation, and employee communications. It also shares cost, quality and utilization results.
Download the case study (requires free account)
Read Harvard Business Review article (requires paid account)
A centers of excellence (COE) program designates facility service lines for clinical excellence and cost-efficiency. Centers of excellence may operate simply as transparency/designation programs, or can be bolstered by differential benefit design incentives. Within the past decade, new vendors have entered the market, offering COE programs that employers can use to carve out services from their main health plan(s). These vendors typically offer a travel benefit to help members access COEs outside their home MSAs, and frequently pay the COEs with a bundled payment.
Underuse of High Value Care
November 26, 2018
Altarum Healthcare Value Hub
Research shows that Americans are only receiving 55% of recommended preventive and maintenane care, so the goal of reducing low-value care needs to be balanced with an emphasis on increasing the provision of high-value care. The Healthcare Value Hub offers recommendations to address underuse, including value-based insurance design and provider and consumer incentives.
PROVIDER NETWORK STRATEGY
One way to ensure that health plan members seek high-value care is to limit in-network providers to those who can deliver higher quality at a lower price. Narrowing is the classic approach to network design, but more recently, purchasers have shifted the network landscape by adding their own on-site or near-site clinics, or by introducing alternative visit types, such as virtual medicine or home health care.
This section of the website reviews both models of network curation, providing details on model construction, best practices, and case studies from other purchasers’ endeavors.
Narrow and tiered networks
Narrow networks aren’t new. For decades, health plans offered greater savings by cutting out expensive hospitals or health systems, or by negotiating better discounts with those who remained in exchange for volume. More recently, health plans started to offer networks curated on quality performance as well as cost. The resources in this section examine the different types of tiered and narrow networks and explore where network strategy is headed in the future.
Employers’ Forum of Indiana
This overview of tiered and narrow networks explains their typology and prevalence, summarizes savings and utilization outcomes as documented in peer-reviewed literature, and discusses how these models are likely to evolve going forward.
June 9, 2017
Catalyst for Payment Reform
This virtual event explains how high-value provider networks are established, the incentives consumers need to use them, and provides examples of high-value provider networks that have been implemented by employers. The event also features a dialogue between a consumer advocate and a provider about the pros and cons of high-value networks.
Catalyst for Payment Reform
This case study documents how Qualcomm Incorporated (Qualcomm) examined local market dynamics before successfully launching an accountable care organization (ACO) program for its employees and their families. After reviewing health care cost and quality variation, assessing their unique health care market, and evaluating proposals from providers and carriers, Qualcomm selected Scripps Health and UnitedHealthcare for its direct contract arrangement, designed to deliver a superior experience for patients.
Download the case study (requires free account)
Alternative sites of care
Narrowing or tiering a network isn’t a viable option in every market – particularly in markets dominated by a single hospital or health system. That’s why some purchasers are thinking outside the box. Instead of cutting providers out of the network, they’re inviting in new providers through onsite and near-site clinics and introducing virtual medicine as an option for their health plan members.
Catalyst for Payment Reform
Aircraft Gear Corporation reduced health care costs by 20% when they rolled out their near-site clinic to eliminate barriers to primary care. This case study covers the design features Aircraft Gear considered, how they found the right providers, and how they rolled the new program out to their health plan members.
Download the case study (requires free account)
June 4, 2018
Catalyst for Payment Reform
CHG Healthcare saved over $463,000 through its telehealth program, which they implemented to address the health care needs of their traveling workforce and reduce unnecessary ER utilization. The case study explores how CHG designed its telehealth strategy, identified the right partners, and launched a successful implementation.
Download the case study (requires free account)
June 6, 2016
Catalyst for Payment Reform
The information in this guide is intended for purchasers of health care interested in understanding more about the value of telehealth and how it can be used not only to improve access to and satisfaction with health care for a given population, but also to generate savings and stimulate competition among health care providers.
Catalyst for Payment Reform
Learn from Google’s former Healthcare Delivery Benefits Manager how Google’s benefits team utilizes innovative communication channels to build awareness among employees about in-network, high-value health care options, including telemedicine, on-site clinics, and home health care.
PROVIDER CONTRACTING STRATEGIES
Frustrated with health insurance companies’ inability to exact reasonable prices from hospitals, some purchasers have taken matters into their own hands and negotiated contracts independently. This section examines the contracting approaches purchasers have pursued and the outcomes they achieved.
Medicare PLUS contracting
A “Medicare PLUS contracting” strategy throws down the gauntlet, stipulating that a purchaser will pay no more than X% of what Medicare pays. Take it or leave it. This strategy is also occasionally called “Reference Based Pricing” (because Medicare is the reference point) but unlike the RBP version of benefit design, a Medicare PLUS strategy places the mandate on hospitals rather than consumers.
March 7, 2019
Reference-Based Pricing – Leveraging State Purchasing Power to Lower Health Care Spending
National Academy for State Health Policy (NASHP)
Marilyn Bartlett (Montana) and Dee Jones (North Carolina) discuss how their states implemented Medicare PLUS contracting for their state health plan employees, including the challenges they faced in compelling providers to accept this strategy and how they overcame them.
National Public Radio
This article takes a closer look at Marilyn Bartlett and her bold strategy to mandate Medicare Reference Pricing for Montana’s state employee health plan. Bartlett’s success hinged on two factors: obtaining hospital pricing data and engaging stakeholders to pressure hospitals to accept the Medicare reference-based contract.
Direct contracting
It’s a fair question: if a giant health plan can’t trade volume for discounted pricing, why would a single purchaser have more leverage? But according to a recent poll from the Kaiser Family Foundation, 8% of large, self-funded employers are currently pursuing direct contracts with local hospitals/health systems or using an alternative TPA to carve out specific services (sometimes known as a Centers of Excellence or COE model). This section explores options for direct or semi-direct contracting and provides a blueprint for purchasers who want to pursue these strategies.
June 27, 2020
Catalyst for Payment Reform
Take a deep dive into direct contracting strategy with CPR. Resources include blog posts and articles, webinars and case studies from employers who have successfully launched their own direct contracts, as well as a 300-level online course covering everything from the pros and cons of a direct contracting strategy to the operational blueprints for launching one.
June 4, 2018
Catalyst for Payment Reform
What did one self-funded purchaser do upon seeing how vastly quality of care varied for spine surgeries? They designed and implemented a successful center of excellence program. Learn the ropes for direct contracting, benefit design, and what it means to collaborate effectively on a COE program from Walmart Stores, Inc. and its key partners.
Download the case study (requires free account)
Catalyst for Payment Reform
This case study documents how Qualcomm Incorporated (Qualcomm) examined local market dynamics before successfully launching an accountable care organization (ACO) program for its employees and their families. After reviewing health care cost and quality variation, assessing their unique health care market, and evaluating proposals from providers and carriers, Qualcomm selected Scripps Health and UnitedHealthcare for its direct contract arrangement, designed to deliver a superior experience for patients.
Download the case study (requires free account)
There is strength in numbers. Efforts to use data to improve health care value will be amplified by banding together with like-minded advocates. This section of the Employer Price Transparency Project offers tools, reports and research to convene an aligned coalition, and also engage local, state and national policy stakeholders to advocate for change.
Convening a coalition of stakeholders
This section offers an overview of the value of local and regional stakeholder coalitions, and a portfolio of tools and templates you can use to create your own coalition and host your first meeting on how to leverage hospital price transparency in your market.
June 27, 2020
Employers’ Forum of Indiana
Use this template to invite like-minded purchasers to discuss hospital pricing data in your market, and align on a strategic approach to achieve greater health care value and affordability.
June 27, 2020
Employers’ Forum of Indiana
Use this survey to collect preliminary information about your coalition participants including their size, current portfolio of contracting and network solutions, and strategies they would like to pursue as part of your coalition. You can then use the presentation template and Excel tool below to turn your survey data into visual results.
June 27, 2020
Employers’ Forum of Indiana
Use this presentation template to present at your first coalition meeting. The template includes talking points and information on the forces that drive price variation and health care cost inflation and the RAND Hospital Price Transparency study. Customizable slides walk meeting participants through hospital price results for your market, and tee up discussion of participant preferences and next steps.
Employers’ Forum of Indiana
Using the RAND Hospital Price Transparency Study data, this Excel tool provides charts and graphs you can use to populate your meeting presentation. In each tab, select your market of interest, and graphs and tables will automatically update with relevant data and key findings. (Details provided within the Instructions tab of the Excel file).
May 22, 2019
RAND Corporation
RAND Hospital Price Transparency Study participants can request a personalized report that provides pricing information for their most heavily used hospitals. RAND’s analysis compares purchaser paid amounts to hospitals against Medicare allowed amounts, and models savings if multiples of Medicare rates were used. The sample report illustrates the full scope of analysis participating purchasers receive.
September 28, 2017
Additional Background: The Value of Regional Business Coalitions
Catalyst for Payment Reform
As purchasers strive to achieve value in their health care spending, they can look to regional business coalitions for support. Listen to the experts discuss business coalitions, including how they engage in regional health care issues and implement solutions on behalf of their members.
Group purchasing
Facing unabating health care cost inflation, many purchasers have lost patience with traditional health plan products and are looking for alternative solutions — like contracting directly with a health system or creating a customized provider network. But it is the rare purchaser who has enough localized volume and market leverage to create new health care partnerships or products independently. That’s why some employers have banded together, pooling their membership volume to amplify their influence and purchasing power. Although many group purchasing coalitions have formed over the years, only a handful have achieved sustained success. The links below provide insight into why some group purchasing efforts succeed, why some fail, and how to replicate successful models in your market.
September 3, 2019
Cheryl DeMars on Achieving Longevity in Group Health Care Purchasing
Catalyst for Payment Reform
Listen in as CPR’s Suzanne Delbanco calls Cheryl DeMars, President & CEO of The Alliance – a cooperative of 240 self-funded employers pooling their purchasing power to control costs and improve quality. Find out why the Alliance was formed and how it continues to deliver strong results through innovative strategies, like Quality Path and high-value primary care.
Colorado Health Institute
Learn how Peak Health Alliance, a group of large and small employers in Colorado, used the state’s all-payer claims database (APCD) to negotiate directly with providers and lower the cost of health care. With projected savings of over 50% compared to 2019 premiums, the Peak Health Alliance began offering coverage in their new health plan on January 1, 2020.
Employers’ Forum of Indiana
The Colorado Business Group on Health is one of the business coalitions engaged with the RAND Employer Hospital Price Transparency Study. Andréa Caballero, Program Director for Catalyst for Payment Reform, interviews Colorado Business Group on Health (CBGH) Executive Director, Robert Smith, to learn how CBGH is using the findings to shape purchaser-led action in pursuit of better value health care for patients and purchasers.
September 1, 2020
Catalyst for Payment Reform
Catalyst for Payment Reform’s research assesses the effectiveness of past and current strategies to aggregate volume at the local level through group purchasing and other approaches, and describes viable models that enable aggregation of covered lives at a local level.
Policy advocacy
Working individually or as part of a coalition, there are multiple strategic options purchasers can choose from to create greater value for themselves and their plan members. But beyond negotiations between purchasers, health plans, and providers within the delivery system, federal and state policy changes can have a powerful, widespread and lasting impact on transparency, anti-competitive practices, and even regulate prices. The section below sheds light on some of the legislative and regulatory strategies purchasers can advocate for that may reduce health care cost inflation.
June 27, 2020
Employers’ Forum of Indiana
This model public statement is designed as a template “call to action,” outlining policies aimed at health plans, providers, and state and federal government. Purchasers – or coalitions of purchasers – can use this template to demand greater price and quality transparency, insist on full and unobstructed rights to their claims data, and shine a light on the need to end providers’ and health plans’ anti-competitive business practices.
April 9, 2019
Catalyst Payment Reform
In an increasingly complicated and blurry landscape, stakeholders across the health care industry are searching for ways to control health care costs, improve quality, enhance access to care, and maintain fair market power. This webinar, featuring David Muhlestein, Chief Research Officer at Leavitt Partners, and Niall Brennan, President and CEO of the Health Care Cost Institute, brings some of these issues into clearer focus – highlighting complex areas of health care strategy that may need policy solutions at the state and federal level to catalyze change.
June 5, 2017
Altarum’s Center for Payment Innovation & Catalyst for Payment Reform
Altarum’s Center for Payment Innovation (formerly the Health Care Incentives Improvement Institute) and Catalyst for Payment Reform (CPR) published this comprehensive report card on both state health care price transparency and physician quality transparency. Check out how your state performs in both!
June 27, 2020
Employers’ Forum of Indiana
Provider consolidation – health system mergers and acquisitions of independent provider practices – drives up prices, has minimal to no impact on quality, and the trend shows no signs of abating. This does not, however, mean that ongoing consolidation is inevitable. This issue brief outlines strategies stakeholders can take to soften the impact of provider consolidation and help retain provider independence where it exists.
September 2, 2017
The Urban Institute
In this article, Robert Berenson, MD, reviews the existing literature on the quality and cost impacts of vertical integration – the purchase or merging of independent provider practices and hospitals/health systems. Dr. Berenson argues that our laws and regulations should, at the very least, not encourage or incentivize vertical integration, and that structural changes to physician fee schedules are necessary to further reduce incentives for consolidation.
Altarum Healthcare Value Hub
This report introduces a framework (“roadmap”) that policy makers and advocates can use to evaluate the efficacy of health care policy solutions. The report deploys this framework to evaluate local health care policies, highlighting solutions with the greatest evidence base and potential for success, and includes a toolkit highlighting federal, state and local policies to achieve health system transformation.
Employers’ Forum of Indiana
Consolidation and the market power shift toward health care providers drives up prices and has minimal to no impact on quality. But even in highly consolidated markets, policies at the federal and state level can prohibit anti-competitive practices and tamp down inflation trend. This issue brief examines measures state and federal policy makers can take – even in highly consolidated markets – to demand transparency, mitigate price inflation, and prohibit monopolistic behaviors of large and/or influential health systems.
