Consumer Protections: More than Appeals and Grievances

  ·  Health Policy Hub   ·   Renée Markus Hodin

This is the next post in an inaugural blog series outlining the policy priorities of the Center for Consumer Engagement in Health Innovation. Each blog takes a deep dive into one of the six areas we believe must be addressed to achieve better care, better value and better health.

Transforming the way we deliver and pay for care holds the promise of better health outcomes and improved quality of life for the tens of millions of Americans who find themselves falling through the cracks of our disorganized and fragmented health care system. Among these populations are frail older adults, people with disabilities, those with multiple chronic conditions, children with special health care needs and people with mental illness or substance use disorders. Spurred by the Affordable Care Act, there are myriad demonstration projects, pilot programs and initiatives underway to achieve better care, better health and better value.

While the promise health system transformation initiatives may offer is considerable, so too are the risks to consumers. For some, the specter of 1990s-style managed care looms large, and any attempt to introduce payment reforms, especially changes that impact the most vulnerable populations, is viewed with great suspicion. The fear – particularly with any initiative that puts providers at risk – is that an inherent incentive is created to ration care or avoid patients who have complex care needs in order to reap greater profits. Others worry the use of limited networks (as a tool for achieving cost savings) will place unreasonable limits on choice or force patients to separate from providers with whom they have ongoing long-term relationships.

These are real concerns. It is incumbent on policymakers designing new initiatives to ensure that consumers enrolled in new programs are protected against plan or provider misconduct, as well as against unjust restrictions on choice. A traditional way of creating these protections is crafting a robust set of grievance and appeals procedures. And, to be sure, these rights are essential. These procedures must be easy to understand and utilize, there must be fair hearing protections, and plans or providers must continue to provide services to consumers throughout the course of an appeals process.

But building consumer protections into health system transformation is so much more, and in some cases requires advocacy around issues not typically seen as being part of the consumer “beat.” These include:

Payment: While normally seen as the province of plans and providers, payment rates – that is, getting them right – is fundamentally a consumer protection issue. Put simply, if payment rates are inadequate, the incentive to ration care is heightened. And the consumers most at risk are those with the greatest needs since they also account for the greatest costs. That’s why, to cite one example, we are pleased  CMS is fine-tuning the risk adjustment system for plans participating in the demonstration projects aimed at improving care for those with both Medicare and Medicaid, often referred to as “dual eligibles.” A fair payment structure that takes into account the needs of the beneficiaries being served, especially those with the greatest needs, is truly the most foundational consumer protection

Quality Measurement: Measuring what matters most to consumers is the way to get the most “bang for the buck” and serves to mitigate potentially negative effects of health system transformation. Among the measures that matter most is care consistent with patient’s goals, values and preferences. We also think the measures outlined in the Institute of Medicine’s Vital Signs report capture many key domains of health.

Meaningful Consumer Engagement: Ensuring a meaningful role for consumers, family members and advocates on advisory councils, for example, serves as a further means of protecting consumers. These types of bodies can serve as an early-warning system for problems arising in new systems of care, and provide the essential consumer-management feedback loop needed for ongoing service improvement. 

Transparency: New payment and delivery systems require new levels of transparency with regard to design, implementation and reporting of outcomes. Reporting must be consumer-oriented so that results are understandable and data is offered in ways that reveal progress, or lack thereof, on achieving health equity. Additionally, beneficiaries must be fully informed and engaged on their choices, for example, to be part of an Accountable Care Organization or a Patient-Centered Medical Home.

It’s not an accident that these consumer protection priorities largely track the Center’s policy agenda. As our health system shifts away from fee-for-service and toward more risk-based payment arrangements for providers, our central task is to ensure that this transformation occurs in a way which benefits consumers, particularly those who are most vulnerable.

Join us on this journey!