Reality Check for the Self-Insured Payer
Nura focuses on self-insured payers (large employers and state medicaid programs) because they have the greatest economic incentives, operational ability and legal flexibility to institute Demonstration projects.
Though employers cite escalating healthcare costs as a top three threat to their business, the root cause of runaway costs lay in the design and operation of the billing/payment system. Historically constructed as an invoicing mechanism for physicians, the payment system captures no data on the efficacy of clinical procedures. Patient care is paid for because it is delivered – whether it worked well for the patient or not at all. Alternatives to conventional care practices are typically not offered because the payment system does not include procedure codes that enable reimbursement for such care.
Of the few IM compatible codes that do exist, the underlying algorithm that determines provider reimbursement is not patient outcome driven and leads to a miniscule payment. Even if one was discovered, an inexpensive "cure" for a chronic disease is very difficult to promote in a marketplace that would see a decrease in revenue as a result of championing for that cure.
This leaves patients and payers of care (employers, state) as the most plausible (aligned in purpose) drivers for determining the effectiveness of patient care methods. Historically, neither of these stakeholders has had a tool with which they could identify patient care procedures that work, let alone work best—until now.