3 value-based care considerations to prioritize in a health plan
COVID-19 has driven home the potential of value-based care to impact incentives, improve quality, ensure appropriate care, and lower costs in a health…
In the value-based care delivery model, providers are paid based on patient health outcomes. Under agreements, providers are rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an evidence-based way. This differs from a fee-for-service approach, in which providers are paid based on the volume of health care services they deliver. The “value” in value-based health care is derived from measuring health outcomes against the cost of delivering the services.
Challenges & opportunities
For employers and benefits consultants, evaluating health plans on an annual basis prior to open enrollment should include some hard questions about whether these plans are keeping up with the digital transformation taking place in health care, which is truly essential for meeting employees’ evolving needs. Leading plans are innovating to address the cost per employee in employer-sponsored health insurance. In 2021, this jumped 6.3%, representing the highest annual increase since 2010, leaving employers, advisors and payers alike to grapple with an array of options and opportunities to drive health care costs down.
They have tried before. When high-deductible health plans were introduced, employees were incentivized to make better health decisions with some financial rewards for doing so. However, research shows that some employees were discouraged from preventive care, and that employees reached a limit in how much of the financial burden for their care they could absorb. In recent years, employers have also implemented a variety of wellness programs, including onsite exercise classes, education, non-smoker incentives, and points and rewards programs. While results are mixed in terms of driving down long-term costs, these and similar perks are now an employee expectation in recruiting and retention. They are also now an integral part of corporate culture in many places.
Very few payers have been able to launch large-scale value-based initiatives that deliver on the promise of true value-based care, and this should be of concern to employers who need to drive benefit costs down while remaining an employer of choice. Analysts at WTW polled 636 employers representing 10 million workers and found that 94% are naming health care costs a top priority over the next two years. Additionally, nearly two-thirds of the surveyed employers (64%) said they will be taking steps to address affordability over the next two years. These efforts include enhanced low- or no-cost benefits, named by 41% of the employers, as well as addressing outcomes and care quality, named by 55%.
All of this is to say: standing up the best health plans for employees is not a simple task and is not a one-size-fits-all approach. To move forward, keep hard-hitting questions to your health plans on frequent rotation and assess their responsiveness with honesty and clarity. As you evaluate health plan vendors, ask: What steps are they taking to integrate their operations under a single interoperable system? Are they leveraging a digital-first approach in their pursuit of value-based care? How close is the health plan vendor to offering real-time data when interacting with members? Will the member get correct information about their benefit design, claim status and costs in one phone call? Or will they be transferred multiple times? Will their website and member portal give information that matches their experience when they make a co-pay at a provider’s office or pharmacy? What type of member awareness materials and tools are offered online? Can members find in-network preferred provider recommendations on the plan’s website or member portal using a Find Provider function? Does the plan offer to show estimated co-pay information for outpatient and preventive care services?
Below are three key considerations to prioritize when partnering with a health plan.
Three key considerations
1: A holistic approach The pandemic has particularly highlighted the importance of holistic benefit strategies that address both the physical and mental health of workers while engaging employees and providing value. Mental health apps and telehealth capabilities are critical to a holistic approach, along with member education tools and personalized health programs. These tools can help organizations extend their reach across a greater span of critical touchpoints, uncover valuable opportunities to intervene in a proactive manner, and deliver a modern experience that improves member engagement.
Don’t settle: a strong clinical team well-versed in technology at a payer organization should be able to address questions and concerns about risk stratification, utilization, health outcomes, grievance resolution and member engagement.
2: Tiered benefit plans Tiered benefits allow employers to manage what they pay for in health care services and empower patients to select a plan design and network that fits their financial needs and personal preferences. Customizing these benefit tiers is a crucial component in choosing the health plan that will meet the cost and benefit needs of employees. For example, healthier employees at lower salary levels may gravitate toward higher deductible plans with lower premium costs. More experienced employees may have sufficient income to afford higher premiums, but more complex health needs, and a desire for a broader provider network. A strong payer organization using up-to-date technology should be able to roll out a variety of benefit designs quickly for your consideration and to adapt them to your needs. The season prior to open enrollment is no time to be waiting on critical data from a vendor plan.
3: Member satisfaction At the end of the day, member satisfaction must be a driving force for an organization, and consumer expectations are higher than ever. With technology that puts the world at their fingertips, they are not going to be satisfied with a health plan that has a poor technical user interface. Satisfied employees with strong and versatile benefit plans can support recruitment and retention efforts. Employers and their advisors can and should look closely at member satisfaction scores and demand from their plans that the technology matches the talk.
Conclusion To achieve true value for the health ecosystem – payer, provider, employer, and member – benefits advisors and their employer clients should expect that claims management, payment integrity, care management, and member engagement to work together seamlessly. While progress has been made among these parties when it comes to exchanging data through standard interoperability protocols, ultimately, payers who have embraced and modernized their systems and architecture for a value-based care environment will best serve employers, stakeholders, and their staff members.
As employers seek to align with payer-partners who can share responsibility for prevention, care delivery costs and high-quality care, now is the time to embrace modern technology innovations that will put the value in value-based care.
Dan Vnuk is the Chief Technology Officer, GuidingCare Division, at HealthEdge.