If you offer an employer-based health plan hopefully you’ve paid some attention to the Consolidated Appropriations Act of 2021. The Act amends the Retirement Income Security Act of 1974 (ERISA) and imposes a series of new and complex obligations on health plan fiduciaries that mirror the rules that govern retirement plans. If you offer a group health plan you are a fiduciary. It doesn’t matter whether you’re fully insured or self-funded. Your fiduciary obligations are the same. And you cannot transfer those obligations to a third party (like a health insurance carrier, or a TPA). Among other things, ERISA fiduciary duty includes the duty of prudence. That could arguably include the duty to prudently protect your employees and families’ health and welfare when receiving medical care paid for by the health plan you sponsor.
Half the doctors in America are below average. The other half are above average. A simple, logical statistic that requires no thought. But how do you tell the difference? How do you know if the doctor you’ve chosen (or was chosen for you) to replace your knee is the best available surgeon? The only safe way to know that is to have information about the outcomes of their previous surgeries. What’s their “track record”? You need to know how many times that surgeon has performed that surgery successfully. That might help you to determine his expertise. You should also know how many people died as a result of his surgeries. You may think that it’s unreasonable to think you could die from a knee surgery but it’s not. I have a personal story where an acquaintance in her 50’s went into a hospital for a knee replacement and never left. She died of Sepsis as a result of her surgery. You’ll want to know the surgeon’s rate of complications as a result of his work. It might also be helpful to know how many of his patients had to be readmitted to a hospital following discharge. And would it make a difference if you knew whether the doctor had been sanctioned by a medical board or sued over previous knee surgeries? You should have similar information about the outcomes and safety record of the hospital you’ll be using as well. I can show you a heart surgeon who has a quality rating in the 97th percentile of all heart surgeons in America at one hospital and in the 7th percentile in another. If your employees had access to this kind of information you could fulfill your duty to prudently protect them and their families’ health and welfare.
But you don’t have access to performance outcomes and safety data about health providers because your current health plan won’t give it to you. Rest assured they have the data. But they’ve agreed in their PPO contracts not to share that information to protect all of the doctors and hospitals within the network. The fact is all health insurance carriers have access to the same outcomes data. But it’s not in their best interest to share it with you. Instead, they rate their In-Network providers on a five-star rating system based on patient comments instead of meaningful data. You should be outraged that your health plan makes you and your employees blindly navigate through the myriads of providers in your network without providing the information to help you make the safest choice. Especially when they have it. Because choosing the right doctor or hospital can literally be a matter of life and death.
If the health and safety of your employees and their dependents is important to you and you want to do to something about it, you can start with a conversation with me to learn how to readily obtain important outcomes and performance data for your health plan. Providing this information is a crucial part of the strategy I bring to my employer clients. And it’s more than just the information. It includes the clinical support of nurses and doctors to personally help you understand the information and provide professional guidance through the health care journey. Poor quality health care is expensive. It creates additional costs in complications and readmissions – costs that you as the health plan sponsor pay for. And there is a sense of moral satisfaction knowing that your health plan is actually protecting its members from potential medical harm.