The American health care system offers U.S. citizens just about everything they could ask for: highly educated medical professionals supported by the latest technology healing the sick in gleaming facilities.

But for far too many Americans, that system falls short in one critical area: access.

But that's changing. The traditional U.S. model of fee-for-service, clinic-based, insurance-payment-driven health care is crumbling, and everyone knows it. The Patient Protection and Affordable Care Act lit a fire under the smoldering debate around access. Now, more voices are chiming in.

Several themes emerge: transparency, technology and convenience. The three are inextricably intertwined in the pursuit of access, and any solution that does not address that trio will not contribute to a truly accessible health care system.

Of course, the elephant in the waiting room is affordability, which spans and impacts all three of the above. The ability to afford quality care is crucial; however, affordability is not the only barrier. Experts in health care reform believe that through greater transparency, improved telehealth and more convenient services, access can be greatly increased. At the same time, health care should both decline in cost and become a choice, rather than a stab in the dark.

Transparency: What lies behind the curtains?

For generations, the true costs of medical care and health insurance were hidden. But as studies began to emerge challenging the cost structures, organizations like the National Business Group on Health and Kaiser Family Foundation began to pry open the protective seal around cost.

NBGH has represented the health care interests of major U.S. employers for 15 years. Its strategy is to drill down on such issues as health care centers of excellence, comparative costs of similar procedures, value-based and evidence-based medical care, prescription drug pricing, and self insurance. It tracks trends relevant to managing health care costs and lobbies on behalf of its membership. Because that membership is composed of 450 major employers, NBGH has clout.

The group has challenged both the medical and insurance professions with its research and positions on key issues. For instance, after researching evidence-based care on behalf of its members, the group issued the following statement:

"By some estimates, up to a third of health care spending in the United States is wasted, much of it on unnecessary care that evidence suggests doesn't benefit patients who receive it. Employers can use plan design, coverage decisions, employee communications and health system engagement (e.g., centers of excellence) to encourage evidence-based care that most effectively benefits patients. Evidence-based benefit design can save money too; medically appropriate patient care is most likely to improve health, and healthy people ultimately spend fewer health care dollars."

NBGH is just one of many organizations pushing for greater transparency in health care. And all the research on health care utilization has exposed an ugly truth: Millions of working Americans who have health insurance through their employer can't afford to use it, due to high deductibles and copays.

Nearly half of insured patients who participated in a Kaiser Family Foundation survey said they delayed or simply didn't undergo tests or treatment recommended by their primary care physician due to high associated costs. Other surveys have suggested the percentage of insured Americans who don't use their insurance due to high cost is much higher.

The American Academy of Family Physicians has come out stridently opposed to high-deductible, high-copay insurance plans, arguing employees don't always understand the true cost of their coverage until they use it.

"The high-deductible plan patients will not make their appointments because they have to pay for primary care," says Ada Stewart, MD, a primary care physician with a community health clinic in Columbia, South Carolina. A member of the academy, she supports its lobbying efforts to include primary care as a free benefit in health plans.

"While some insurers, politicians and employers are pushing for lesser coverage, the patients are not getting the care they need. In the end, it costs us so much more when people do not get primary care."

Brokers are joining the transparency crusade as well. Jeff Fox of HJ Spier is among a new breed of broker who encourages clients to get creative about employee coverage models. Fox and a colleague partnered with the Hendricks Regional Hospital system in Danville, Indiana, to create an option for one high-deductible employer health plan.

Employees can choose between a traditional wide-coverage plan, where they pay more of the cost of care, or a narrow network. Large urban hospitals and clinics in Indianapolis are included in the traditional coverage plan. Hendricks Regional, which has several facilities outside Indianapolis, serves the narrow-network plan members. Eight in 10 employees chose the lower-cost narrow network.

Fox recently inked an agreement with a group of suburban health organizations (SHOs) ringing Indianapolis that will open up the dozen hospitals, including Hendricks, to direct-contracting by employers to cover their workers. SHO members negotiate contracts designed to save employees and employers money, drive more business to the lower-priced SHO and lead to more-efficient utilization of services.

"The way we are rolling this out is to let employees choose what they want," Fox says. "If they go with the SHO, they have fewer providers on the list, but we'll reduce their out-of-pocket or even waive it. That makes it so they can afford good health care—they can actually use their insurance."

"Brokers need to start asking themselves, 'How are we helping employees to spend less money on health care, and steering them toward quality health care?" says Rachel Miner, founder of Thrive Benefits. "Brokers have been brainwashed on the network discount as the selling point. The ending price is what matters, not the discount. It's a lot more work to save people money and give them a quality coverage plan. Brokers don't want to do it; there are fewer incentives. But in the end, it's better for the client and the employee."

Miner says she regularly encounters clients who have no idea what they are getting for their health care spend. Her job, she says, is to educate them on the true costs, and to offer options that most don't know exist, like direct primary care.

Technology: Focusing on connection

Historically, technology has served medical professionals and patients by developing ever more complex equipment and systems to treat disease and injury. In the past decade or so, technology has emerged that can increase access by reducing distances, waiting times and financial barriers to care.

The Health Resources and Services Administration (HRSA) prefers the term "telehealth" to "telemedicine." To HRSA, telemedicine only describes remote clinical services (diagnosis and monitoring). Telehealth's scope is broader, covering preventive, promotive and curative care delivery. While vendors of technology in this space often choose "telemedicine" to describe what they do, others feel telehealth more accurately reflects how the products and services affect access.

Regardless of the term used, the potential for technology to effectively connect patient to clinician and medical professional to medical professional is finally being realized. From online consultations to take-home self diagnostic kits to remote specialist networks, telemedicine is suddenly everywhere.

With increased adoption by medical professionals, demand for more telehealth services by employers, and broker support for telehealth benefits, adoption numbers are gradually rising. Now, plan members are experiencing access to quality services on their schedule, with a quick turnaround for results. Whether they are scheduling a telehealth visit with their PCP, having data sent seamlessly from a personal monitoring device to their doctor, or getting feedback on symptoms from medical professionals via a teleconference, they see the benefit.

First Stop Health serves as an example of a connective technology supported by a broker and accepted by employees whose plan includes it as a benefit.

First Stop Health is a telehealth network of medical specialists that patient/employees and their physicians can access remotely and receive same-day feedback. Utilization among plan members exceeds 50 percent, says CEO and co-founder Patrick Spain.

Why? The immediacy of the access to higher level medical advice matters. But just as important, the benefit is free to the plan member.

"They offered [telehealth] benefits before, but as a copay, and without any promotion. We insist that employers help us educate employees, and we won't charge a copay or anything else," he explains.

At the other end of the patient spectrum, telehealth offers access to care for many who have never had it.

Technologies that connect patients to physicians address the current shortage of clinicians that, many experts predict, could reach crisis proportions in the next decade. The true magnitude of the shortage has been greatly debated. But all those studying the shortfall agree that a concentration of physicians in major cities has created a huge shortage of care for those in outlying areas.

Many applications of telehealth target this issue by increasing the number of patients a primary care physician can handle.

Terri Hobbs, former executive director of Housecall Providers, understands the game-changing role telehealth can play in access. Housecall Providers (now part of Portland insurer CareOregon), exclusively makes home medical visits. Many of its patients are truly homebound, often trapped alone in homes far from Portland's health care providers. Theirs is lack of access in its purest form.

In a home medical practice, physicians often travel 30 to 45 minutes between patient visits, which often last an hour. Insurers have balked at reimbursing for that "windshield" time, as well as other necessary elements of this type of care, including telehealth. Result: Patient panels per PC tend to be low, and their income reflects that.

"Telemedicine can extend a house call practice's panel," Hobbs says. "You can space out how often to see them in person [through use of telehealth]. You still need to see them in person, but maybe that's a triage nurse, not the PC every time."

Caregivers are crucial in this scenario, because homebound patients with multiple chronic diseases often cannot easily use telehealth devices. But the option provides a critical link to quality health care for those who previously rarely saw a doctor.

In rural Texas, telehealth is opening access to thousands of people who otherwise would receive limited health care.

Telehealth "has always had great potential to increase access to care, especially in places like West Texas," says Billy Philips, PhD, executive VP and director, at the F. Marie Hall Institute for Rural and Community Health, Texas Tech University Health Sciences Center.

He ticks off the disorders and conditions that telehealth addresses in his region: mental health consultations, chronic disease management, physician to physician consultations, dermatology diagnosis, guided practice models. "It's good now and it's getting better by the day because technology is exploding."

One caveat he notes: Insurers are lagging behind the gains made by telehealth.

"Insurers won't pay for telehealth," he says. "Here we are increasing access by increasing our panels through telehealth. Outcomes are virtually the same [as in clinical exams]. And yet the insurers are not going to reimburse that? Doesn't make sense."

But, he adds, "We're seeing more doing it. It's definitely where we're headed."

Convenience: What I want when and where I want it

Previously, the role played by convenience in the access equation dictated that care had to be convenient to the clinician. The clinic health care model requires the patient to come to the doctor, who then sees as many patients as possible in the rabbit warren that is the clinic.

As research has proven that regular medical checkups and access to preventative care lead to better health and lower claims, convenience has become the province of the patient.

Onsite clinics are perhaps the ultimate convenience. The NBGH reports that more than half of its members now have one. The percent has grown from 47 percent to 54 percent in just two years and is expected to reach 66 percent by 2020. That's because employees use them.

"Onsite and near-site health centers have been shown to improve employee health and well-being, increase access to quality health care, enhance employee productivity, reduce health care costs, and improve employee recruitment and retention," NBGH says.

Once available only to employees of large employers, companies like Activate Healthcare are opening the onsite clinic doors to small business employees.

The company partners with multiple small employers in a geographic location to build, staff and maintain a brick-and-mortar clinic located close to all employers. In Defiance, Ohio, a small town, nine small employers now share the cost of an employee clinic.

Employees can use the primary care services provided at the clinic free of charge. They are also covered by a "skinny" plan in the case of catastrophic illness or injury. Physicians are paid a salary and do no paperwork. Plan members say they are able to make same-day appointments, rarely have to wait in the waiting room, and get results almost immediately. Debra Geihsler, principal and co-founder, describes the model as "capitated concierge home-type solutions for employees only."

Co-founder Peter Dunn adds, "Activating the patient is at the center of our model. Activated patients have much better outcomes. But it has to be convenient for them."

Patient convenience is driving many new products and services. Huge strides have been made in the remote monitoring field. Tytocare offers essentially an annual exam take-home kit. It calls it's product "a complete virtual visit, including physical exam, designed to replicate a visit to the doctor's office."

With TytoCare, doctors can diagnose more conditions more accurately, making the promise of telehealth a reality. Tytocare's Anu Nadkarni, VP Payer Solutions, says the exam kit was designed to be "almost impossibly easy to use" for the patient. "UX design is really important," she adds. If people have to struggle to figure out how to use a product, they won't use it.

"Employees find it is easy to use, they can get the care they need from home, and send the data to their PC. It's convenient, and that great access to care drives the engagement."

Yet sometimes, the most powerful telehealth device can be something that fits conveniently in your pocket: your phone.

Texas Tech's Billy Philips says his son, a millennial, recently witnessed "transparency, technology and convenience" in action. A friend had a sore throat and wanted to know if it was strep. His health plan included free telehealth visits. He called his PC and described his symptoms. The PC had him take a photo of his throat with his phone's camera and send it to him. "Yep, that's strep!" the doctor said. A prescription for antibiotics was delivered to him.

"He never left the house!" Philips says. "He understood the benefits in his plan and he could afford them. That's progress!"

Read more about how access to health care is increasing:

Instant Insights /

Expanding access to health care

More From HR Executive

Related Stories

Recommended For You