Beginning around 1980, the U.S. began to diverge from its peer nations where it began to significantly increase health spending, yet it failed to improve healthcare outcomes.
Around the same time, consumers increasingly spent a higher percentage of their income towards healthcare services, creating a significant burden for many family budgets and a barrier to care for the chronically ill. These trends are not sustainable for consumers, but also create a significant burden on employers as they continue to provide health insurance coverage to almost 50 percent of the American population.
New products and solutions are needed that better address both the employers and consumers’ needs to access better care at a lower cost. This starts with providing clarity to the nature of the solutions required, which involves enabling a better balance between disease care and treatment; and an increased focus on health promotion and prevention across improved benefit design, experience design and clinical models.
It begins with more simplified health plan product designs that integrate with and complement high-value care delivery systems to enhance consumer value, health status, and economic sustainability. Innovative payer and provider organizations have begun to more meaningfully partner and co-design health benefits that encourage members to self-care as well as educate consumers to improve their health literacy, avoid cost surprises and maximize the value of their plan. Promising benefit design opportunities towards health improvement and management include lowering cost barriers to 24/7 virtual care, primary care visits, and other routine care and proper disease management, such as diabetic education and supplies; combined with novel patient engagement initiatives.
This issue is particularly pressing as a recent report by the U.S. Federal Reserve highlighted that four out of 10 adults in the U.S. could not cover an unexpected $400 expense, and when deductibles for many Americans exceed this amount, with coinsurance hard to understand by most consumers. New insurance products that eliminate coinsurance are making health plans easier to understand, and combined with more standardized copays for office visits, are ensuring costs are more predictable and transparent for the consumer. Providing free access to health coaches and patient navigators are also helping ensure consumers receive additional support as they make important health decisions, especially around potential ER and specialists visits.
As many leading health policy experts have pointed out, medical care is one of the less important determinants of health outcomes, with socioeconomic status and other societal factors exerting a larger influence on life expectancy. Leading organizations have begun to mobilize multidisciplinary care teams or holistic care teams, whose providers implement initiatives that truly help consumers be healthier overall and not just step in to help when individuals are sick.
A holistic care team will differ from patient to patient, from one community to another, as it should be completely customized to the individual and their needs. However, typically a team can consist of a dedicated medical director, pharmacist, nurses, social workers and diabetic educators who support patients and their families with their complex needs face-to-face.
The goal is for all of a patient’s providers to know about treatments, medications, lab results and health history to provide a streamlined care approach. A critical component of such programs is to bring the patient into their care plan, with providers encouraging the patient to play a more active and informed role in their healthcare decisions. This helps the patient consider their overall health, knowing their provider wants them to remain healthy and isn’t only interested in seeing them when they are sick. These teams typically target high-risk members that generate more than 50 percent of the cost. They provide care management closer to where members live to determine if community and environmental factors might be influencing their health.
This high-touch, personalized and hyperlocal care management approach can successfully connect members to community-based programs and social support resources, such as a fitness facility or group therapy sessions as needed. While it may seem time intensive to focus care on the high-risk members and provide a team of providers for each, this will help keep members out of the hospital, saving them and the employer group costly expenses and medical bills.
While it may be tempting to primarily focus on just the high-risk, top 5 percent of spenders, the reality is that there is significant volatility and turnover from year-to-year among these top spenders. A recent study has shown that three out of the five top spenders in any given year were not top spenders in the prior year. With the advent of new provider-payer partnerships, improved surveillance focused on health and disease vulnerabilities is achievable through data sharing and analytics from real-time clinical data from health records and claims data.
This allows clinical teams to provide early outreach to rising risk patients and ensure earlier access to key disease prevention and management activities that avoid future hospitalization. It also results in greater care coordination and more personalized care plan that maximizes the providers’ ability to provide timely guidance and support, especially during a vulnerable and challenging time for most chronic and rising risk condition-specific patients.
It is unlikely the cost of healthcare will improve, and its high cost could negatively impact more and more patients if providers do not work to improve the overall health of their local population. The focus must shift from traditional medical conditions and treating the sick to becoming advocates for healthy living, developing more simplified benefit designs, with personalized care plans and taking a one-on-one care approach for each patient. Only then, with a unified approach, will providers and payers ensure healthcare is affordable in the U.S.
About the Author
Genevieve Caruncho-Simpson is the chief operating officer of Texas Health Aetna. Leveraging the strengths of two leading organizations, Texas Health Aetna is blurring the lines of traditional health care plans and health systems to create a truly integrated solution that’s simple to navigate and puts the member’s experience first. The local health plan is committed to providing affordable, high-quality health care services and delivering customized care to members throughout the Dallas-Fort Worth metroplex. For more information about Texas Health Aetna, visit www.texashealthaetna.com.