In the News

Guest Op-Ed: Low, Transparent Costs Vital to NM Health Care

Albuquerque Journal
By Mark Epstein, MD, True Health New Mexico Chief Medical Officer

At this year’s legislative session, Rep. Deborah Armstrong, D-Albuquerque, sponsored House Memorial 29 to set up a health care cost, quality and coordination commission. True Health New Mexico supported the memorial in the hopes it would lead to cost transparency and containment. The bill died, but the need for cost transparency and containment is more important than ever.

True Health New Mexico’s medical management team, formerly the medical management team at New Mexico Health Connections (NMHC) and now providing services for both companies, sees measurable results in our advanced practices that lead to cost containment and better outcomes. We hope that some of these successes can translate into statewide policies and procedures.

Rep. Armstrong’s memorial brought to light the areas in which consumers can be more empowered and benefit from more clarity in how they seek care. It promised better care at lower costs, which is good for the consumer, the health care provider and the health plan – and it helps our communities thrive. When the Affordable Care Act (ACA) was created, the guiding principle was that the tired, cynical business model of insurers running away from financial and health risks was no longer acceptable. The ACA challenged insurers to embrace their populations and manage their health.

NMHC and True Health New Mexico have done exactly that by working closely with both the insureds and the medical providers early on in patients’ care to keep insured members out of the hospital. When insurers manage health so that patients have better outcomes and lower expenditures, it is good for everyone, aside from maybe a handful of hospitals that would be disappointed – from a business perspective – to have fewer sick people coming through their doors.

Our team has created an advanced analytic system that uses data from health plan claims and the New Mexico Health Information Exchange to identify and stratify members who are at health risk, and intervene before avoidable health issues occur. For example, we connect with people who, sometimes despite best efforts, simply do not refill their chronic medication prescriptions. We also connect members with primary care clinicians when we identify the need through member outreach driven by advanced analytics.

We have a robust team of case managers and care coordinators, and we are invested in medical management personnel beyond what a standard health plan would do. We aren’t shy about reaching out to the providers, and helping them optimize care and remove barriers for their patients. We regularly have peer-to-peer conversations to facilitate highly coordinated and individually customized care.

We have found that this level of high touch leads to a reduced need for more expensive care. The results speak for themselves:

  • Our members’ historical hospital admission rate runs 41 to 43 admissions per 1,000 members per year – significantly below both the “well-managed” mark of 50+ per 1,000 and the New Mexico commercial average of 55 per 1,000.
  • Our 30-day “all-cause” hospital re-admission rate historically has run between 4.5 percent and 6 percent – again, well below national and local benchmarks, which run from 9 percent to 12 percent for similar populations.
  • Our successes in consumer empowerment showcase the ways in which legislation like House Memorial 29 can help all New Mexicans. The bill stated the need to set up the independent commission because “health care costs are consuming an increasing percentage of the New Mexico state budget, which necessitates that the state seek ways to manage health care costs without causing widespread disruption.”

The state needs to shine a light on the need for cost management and transparency. It is possible and necessary to have cost containment and transparency coupled with excellent care and improved outcomes for New Mexicans.
Let’s urge our leaders in the next legislative session to create new initiatives to lead the nation in more effective medical management and consumer empowerment in health care to benefit everyone.