The one way that primary care can become more valuable than specialty care is when health systems and health plans go at risk. In that scenario, suddenly, you want nobody getting referred for specialty services unless they really need those services, so the incentives on the primary care physician would suddenly shift from steering a lot of patients in for unnecessary care to making sure that appropriateness is the rule. In a risk-based environment, no system can succeed without driving appropriateness.

DMN: What are some interesting things we might be seeing more of down the road as they relate to controlling the cost of imaging?


BK: Given the cost of advanced imaging, it makes sense for any self-funded health plan to develop direct market-based contracts for imaging services. For example, in one market, our clients were now paying $450 for a high quality MRI, with a reading, and had previously been paying $1,750-$3,200 per image through their health plan.

These figures are not unusual. Keep in mind that health care is a big place, and there are lots of opportunities: lab services, dialysis, ambulatory surgery, pain management, Rx management are just the tip of the iceberg. As employers become more aware of this potential and how seriously they've been taken advantage of by the health systems and health plans, you'll see more non-conventional arrangements like this taking hold. You'll see narrow, high performance networks, based on provider-performance data, focusing care into fewer providers locally, and national centers of excellence attracting high cost cases regionally and nationally. You'll see health plans with strong incentives and disincentives for approaches we know work or don't work. And the responsibility for management of high cost cases will move away from the health plans, who have done very little actual management, and into high performance vendors who specialize in ensuring appropriateness.

All this will happen because the system is so highly stressed now, and purchasers can barely stand it anymore, and they're beginning to take action. It's way overdue.

Brian R. Klepper, Ph.D. is Chief Development Officer for WeCare TLC, LLC, an onsite primary care clinic and medical management firm based in Longwood, FL, and Managing Principal of Healthcare Performance Inc., a consulting practice based in Atlantic Beach, FL. He founded Care and Cost, an online professional health care magazine. He is a columnist for Medscape, as well as a regular contributor to the Health Affairs Blog and other expert health care blogs and has provided health care commentary to CBS Evening News, the Wall Street Journal, the New York Times, and others.

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