How employers can make the most of today’s clinical delivery transformation
Employers that rethink the design of their health benefits can enable employees and their families to optimize their care in a rapidly changing environment.
In the last three years, virtual clinical care has become more routine. Eighty two percent of US primary care physicians reported virtual visits in 2022, and 15% reported that more than a quarter of their visits were virtual. Virtual visits have improved access to mental health care, and mental health visits represented between 61% of total virtual visits in the South to 77% of total virtual visits in the Northeast. The technology available today is shaping how patients interact with health care providers and utilize needed care.
Wearable sensors allow patients to share more information with an ever-growing clinical team. For example, our phones can assess the stability of our gait and our clothing can now incorporate e-textiles to monitor temperature or other vitals. This allows clinical teams to offer real-time targeted outreach based on these data streams, whether it’s through a wearable EKG monitor, responsive skin sensors, sleep trackers, or our phones.
Sensor and video data have been widely proven effective to augment real-time, in-person and virtual visits. Patients and providers are increasingly using these technology platforms to enable asynchronous care. For instance, an orthopedic surgeon can now evaluate a patient from across the country by reviewing a patient’s video-recorded exercises. Based on this remote evaluation and any needed radiographic review, a surgeon may recommend surgery even before she has formally met the patient face to face!
Another example of clinical transformation is hospital at home (HaH), which provides hospital-level care to patients in their homes. Pre-pandemic, only a few hospitals offered these services on largely a pilot or research basis. However, remote monitoring tools and telemedicine expansion, as well as the Centers for Medicare and Medicaid (CMS) hospital waivers that facilitate reimbursement, have led to significant expansion of these home-based services. Currently 296 hospitals in 37 states can deliver this type of care.
The change in care delivery has moved into the community, too. Some vendors send clinicians or technicians to patients’ homes to perform evaluations, draw labs or even deliver treatment. This care can be augmented by employees who access onsite clinics in the workplace, including ‘pop up’ in-person primary or specialty care. Mobile integrated health can bring Emergency Medical Technicians to patients’ homes to provide needed non-emergency care. With more pharmacies or other retailers expanding their health offerings, patients will have access to additional care choices closer to home.
The most effective heath care design will keep pace with new technology and approaches. Here are seven considerations for employers as they contemplate how to take advantage, and stay ahead of, these care transformations.
Use data to segment the population and target those who could benefit most from new care modalities
Segmenting the population will allow employers to target communications to those who may benefit from these changes the most and can decrease message overload for other employees. AI-enhanced segmentation, triggered by new claims or consumer information, can identify programs that are most relevant for each individual. For example, if an individual has a new prescription for a diabetes medication, programming to support diabetes treatment may be the most relevant to that individual.
Design plans that offer lower out-of-pocket costs for utilizing more efficient care
Employers can design benefits that decrease cost sharing for high-value services, an approach dubbed “Value Based Insurance Design.” These value-based designs have the added benefit of making innovative care delivery models, like asynchronous or virtual care, more economically feasible for provider networks. But there are limits on how low employers can make cost sharing for employees.
High-deductible health plans with an HSA cannot waive their deductible altogether. Further, zero cost share can have the unintended effect of sometimes encouraging wasteful care. Employers can evaluate the impact of differential co-payments for employees who use these new care modalities and adjust to find the right balance of access, affordability, and quality outcomes. Review of compliance considerations with your company’s counsel can facilitate these changes.
Communicate about non-traditional ways to access available care
Employers spend considerable effort and resources to develop or integrate clinical programs to support their employees and their dependents, but are often frustrated by low rates of engagement.
Employers can develop ongoing marketing campaigns to help employees find these services when they are needed. While some services, like virtual care, may be available to everyone, other services, like diabetic care, may require targeted outreach. Brief and targeted communications that tell stories with powerful narrative are most effective. Communications can be timed around monthly national health awareness campaigns or other company-wide activities.
Offer onsite space for employees to communicate with virtual or “pop-up” providers
Digital and non-conventional vendors that target a variety of conditions have proliferated in the last five years. To foster engagement with these vendors, employers can make space available in their facilities so that their employees can have private health care conversations with a provider or vendor onsite.
Some employers have equipped these workplace spaces with a computer monitor or devices, like a scale, automatic blood pressure cuff, or other technology that will appropriately support care. This space can be dedicated or available only on specific days/times, but when onsite care is available it can enhance engagement with digital or episodic solutions.
Insist on integration of services
Most employers have their health plan, multiple vendors, and individual providers offering a variety of programs to their population. Employers should encourage coordination, including warm transfers and transmission of medical records, especially if prescription changes are implemented. Many employers have periodic “vendor summits” to identify opportunities to better coordinate care across systems. As part of those summits, employers can require carriers and vendors to report metrics to demonstrate effective integration.
Collect data to determine the value of alternative care models
Health plans and vendors routinely share data with the employers that purchase their services. As non-traditional care grows in both size and scope, employers can assess whether those services meet their needs through selective data metrics that ensure appropriate engagement and value of care.
Read more: Location, location, location: Hospital markups on biologic meds ‘double’ the costs
Ideally, these data monitoring and evaluation frameworks are designed at the start of the programs with key goals decided in advance. Employers should use metrics that help to determine whether a virtual or non-traditional service prevents or substitutes for more expensive and less convenient in-person care, or whether it represents incremental care, and is therefore likely to increase total cost of care.
Vendor reporting helps the employer determine the value of the program. Clinical programs provide value through medical claims cost savings (ROI), decreasing time away from work, delighting employees, or helping employers achieve other strategic priorities.
Add coverage for Hospital at Home, if available.
Historically, both payers and providers have been reluctant to reimburse for HaH admissions because of legal, safety, and other concerns. Currently, only a minority of national health plans reimburse for HaH for commercially insured members. Given the rising costs of hospital stays, employers can embrace new sites of care that still deliver high-quality outcomes.
Many health plans have policies that allow for some home services. As health plans add higher level HaH services, they should ensure that the billing is appropriate and does not overlap with the current lower-level home-based services. Health plans should manage HaH programs to be sure that these services are substituting for hospitalizations, and not being offered to patients who would have been sent home anyway.
Conclusion
Transformation in the health care delivery system and improvements in technology offer opportunities to provide better access and lower costs for employers and employees alike. Employers can refine their benefit design, data systems, communications, and infrastructure to take advantage of the evolution of care happening today and stay ahead of the inevitable changes to come.
Patricia Toro, MD, MPH is a senior director in the Health Management Practice of WTW.
Jeff Levin-Scherz, MD, MBA, is a Managing Director and Population Health Leader of the North American Health and Benefits practice at WTW.