How Two Alternative Health Plans Assess Provider Quality and Cost

When representatives of alternative health plans pitch employers, they promote the idea that these plans allow members to choose high-quality physicians and hospitals that keep costs low.

Surest, for example, identifies high-quality, cost-effective providers based in part on data from the UnitedHealth Premium program, according to Will Shanley, senior director of communications at Surest’s parent company, UnitedHealthcare.

Related: Is There an Alternative to the High-Deductible Health Plan? Glad You Asked.

UnitedHealth Premium uses national standardized measures and health plan claims data to compare a physician’s quality performance to a target benchmark. If a physician’s quality performance is not statistically lower than the target benchmark, then the physician would meet the program’s quality care criteria. When evaluating cost efficiency, UnitedHealthcare evaluates both the total cost of care for each patient and cost of each episode of care.

Wally Gomaa at Coupe Health says the health plan has collected quality and cost data from 30 billion health insurance claims from the care delivered to more than 130 million patients. Also, Coupe Health supplements that information with data on physician and hospital quality, patient experience, cost and relationships with other providers. According to Coupe Health, the supplemental data come from Healthgrades, a Denver company that rates the quality of physicians and hospitals; and Medicare’s Hospital Consumer Assessment of Healthcare Providers and Systems, a national, standardized survey tool for measuring patients’ perceptions of their hospital care.

Coupe Health evaluates physicians based on the number of malpractice claims filed against them, the frequency of emergency department use among their patients, how many patients are hospitalized each year and how many are referred for imaging. The company also looks at physicians’ prescription and referral patterns, their risk-adjusted rates of mortality, and hospital readmissions, among other factors. On the cost of care, Coupe Health says it has data on contracted network rates showing that providers who practice high-quality and efficient care have better patient outcomes and that their cost of care is lower by about $5,000 per patient per year.