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Four priorities your health plan must embrace to thrive in the future


Health plans of the future will focus on consumers: designing products, care and services to support improved health.

Health plans of the future will focus on consumers: designing products, care and services to support improved health. 


“Health plans of the future will make it easy for consumers to understand their coverage, and also how to access the best care for their condition. This includes convenience, quality and costs,” says Andrea Walsh, executive vice president and chief marketing officer, HealthPartners. Successful plans “will understand consumer values and preferences using engagement and data analytics. And they’ll use that to support better health and care, both individually and in communities.”

Five to 10 years ago, plans fundamentally focused on two stakeholders-employers and provider networks, says Patrick James, MD, chief clinical officer of health plans and policy and medical affairs at Quest Diagnostics. “Over the last several years, the member has become a key part of the stakeholder triad. Several plans have even designated the equivalent of a ‘chief consumer officer charged with understanding the consumer, as well as keeping an eye on the larger marketplace and competitors,” James says.


Successful plans of the future will also better adapt to shifting healthcare policies. Based on the new administration and Trump’s stated priorities, reduced regulations will likely be a big focus over the next few years, with less utilization review and fewer reporting requirements, according to says Ron Geraty, MD, chief executive officer of AxisPoint Health.

Plans “will answer to market forces rather than government mandate, leading to lower costs,” Geraty says. They will also encourage greater provider alignment by easing and simplifying reporting requirements, he says.

“Health plans of the future will partner with care systems. In doing so, they will redesign more affordable care and advance payment reform. Changes to the underlying business model in healthcare will be another central focus for the future. Care and coverage will become much more integrated. And community health will emerge with increased importance,” Walsh adds. 

To thrive, plans will also need to take a proactive role in managing member outcomes and provide consumers with the resources they need to improve their health, says Clover Health Chief Operating Officer Wilson Keenan. “Health plans must show their value to consumers and providers.”

Here’s more on the above changes, and four priorities your plan must embrace to thrive in the future.

Next: Get your priorities in order



Priority #1: Affordability and convenience

Plans must have an urgent focus on creating more affordable and convenient care, says Walsh. “Helping consumers navigate and find the best care-that includes both quality and cost-is today’s work,” she says. “Health plans and care systems that are able to deliver high quality care in a more affordable way will be the consumer’s choice. The challenges of individual premium increases in marketplaces across the country underscore the fact that access to healthcare and coverage isn’t enough-it must be affordable.” 

HealthPartners, for example, is continuing to move to value-based payments, packaged pricing and total cost of care approaches that are based on health outcomes and quality of care. “Reforming the way care is paid for supports greater transparency,” says Walsh. “Plans will need to provide members with cost and quality data to make more informed decisions about the best use of the healthcare dollar.”

Successful plans will also bring care directly to consumers. HealthPartners’ virtuwell, a 24/7 online clinic, and Well@Work clinics (similar to primary care clinics but located at a work site) are examples of first-generation efforts. More than 250,000 consumers use virtuwell.com and there are more than 20 Well@Work clinics.“Services will also continue to move from in-person and telephonic to mobile and in the community,” Walsh says.

Hospital-at-home programs that enable patients to receive hospital-level care in the comfort of their homes, such as the Johns Hopkins Hospital at Home (HaH) care model, are another example of the shift to remote care. Compared to similar hospitalized patients, HaH patients have better clinical outcomes: lower rates of mortality, better satisfaction, less caregiver stress, and cost savings of 19% to 30%, according to Johns Hopkins.

It’s also critical to provide patients with resources so that they can find convenient care options. For example, Clover has an in-house customer experience team that explains plan benefits to members, connects them with local providers, and resolves issues. “Insurance can be confusing and intimidating, especially to Medicare beneficiaries, so we encourage our team to spend as much time on the phone with members as it takes to resolve their issue and make them feel comfortable and cared for,” Keenan says.

Next: Transparency



Priority #2: Price transparency

The health plan of the future will provide consumers with the tools to evaluate and navigate the healthcare system, says Walsh. “These tools will be customized to individual values and preferences and will include interaction with physicians. Care and coverage will be more integrated-as consumers evaluate how to finance their care.” 

HealthPartners uses measurement tools, such as the Total Cost of Care, to provide members with tailored cost information, Walsh says. “On either a desktop computer or a mobile phone, members can search for specific procedures and see the detailed out-of-pocket cost to them. The information is personalized based on their benefits and how much of their deductible they’ve met. Consumers can view that alongside information about the quality of the provider. This helps members find the highest-quality, most affordable care in each situation.”


When it comes to plan selection overall, Geraty envisions consumers selecting among plans available in individual markets and employer markets based on cost. For the individual markets, there will likely be three main options, he says:

1. An expensive option, offering full benefits and broader networks.  

2. A higher-deductible, lower-cost option with significant copays. These plans are suited for catastrophic care only, and can be a good choice for younger, healthier populations.

3. A middle option that offers more choices for deductibles, copays, providers, and price and benefits options that vary with the wishes of the individual.

Employer markets will offer two options:

1.  A plan selected by the employer with defined benefits and contributions (currently the most widely offered plan).

2. A secondary option giving employees the ability to choose a plan through private exchanges, with defined contribution from the employer, and the individual paying the balance.

Over time, James predicts that in addition to cost transparency, more consumers will demand transparency around value. “Transparency tools have made employers and plan members more aware of price, but quality is still largely a black box; there is no consumer report for health plans. In the future, it’s going to be critically important for consumers to understand the value and outcomes they’ll get from their plan, as well as other coverage options available.”

Next: Digital strategies



Priority #3: Digital strategies


“Regardless of what may happen to healthcare during the Trump administration, the fact remains that consumers are growing more and more accustomed to easier experiences and greater choices in all aspects of their shopping experience, says Dan Hughes, managing director of sales at Softheon. Healthcare is no exception.

“Health plans of the future will not only need to be web-based, but will certainly need to have mobile capabilities and offer a variety of options to consumers with greater appeal to the individual,” he says. “The process will also need to be easier in a variety of ways, and made more interesting for the consumer. These can include wellness and incentive programs that promote healthy lifestyles, real-time outcomes such as instant insurance quotes, and plan management via 24-hour self-servicing channels.”

With wearable technologies such as Fitbit being increasingly available, Hughes predicts there will be a greater emphasis on “well care,” which emphasizes healthy lifestyles, rather than the traditional model of “sick care,” which only focuses on covering treatment after a patient has already become sick.

HealthPartners agrees. This is another reason the organization is focused on online and mobile technology that improves health and supports care.

Clover is also focused on using technology to fill gaps in members’ care and improve their health outcomes, according to Keenan. The plan is building a data analytics platform that continuously embeds insights into the system. This requires pulling charts and combining data streams from lab companies, pharmacies, electronic medical records, and from its own nurse practitioners and customer experience team to get the best possible understanding of members.

“By creating a deep engagement strategy with our members and collecting data around their risk factors, we can drive proactive outreach informed by data,” he says. “For example, our member outreach work flow is run on real-time data, and our call queue is prioritized based on the risk of the members. Our nurse practitioners use an iPad app during home visits that is synced into the system so they have the most up-to-date information about the person they’re seeing at their fingertips.”

Next: Keep it personal



Priority #4: Personal touch

Paul Keckley, PhD, an independent health researcher and policy analyst, agrees that successful health plans will embrace consumerism. But he cautions that the market is not homogenous. “Needs and preferences vary by health and socioeconomic status, preferences for approaches to medicine, et al. It’s not a one-size-fits-all approach to consumerism,” he says.

He predicts a growing number of “customized health plans” whereby individuals, families and employers can choose levels of coverage, clinical care options, and value-added services-i.e., health coaches and access to medical records. “The notion is that insurers will offer a cafeteria approach to their products, allowing customers to package what they want,” he says.

Beyond offering more consumer choice, successful plans of the future will better tailor member outreach based on individual attributes and preferences.

For example, when HealthPartners wanted to encourage more women who were overdue for mammogram to get screenings, it used micro-segmentation data to develop a campaign with three different types of messages. One focused on convenience and affordability, one on the fact that screening was doctor-recommended, and a third on the need to get the screening based on best practice for women turning age 50. “Through that campaign, 551 additional members got their mammograms in a two-month period,” says Walsh.

Another campaign focused on reducing the stigma around chlamydia by increasing awareness of the need for screening for women ages 18 to 24. The plan first tested on Facebook to see what messages would most resonate. Then, it used these messages in a broader campaign that achieved a 1.8% increase in screening rates.  

It used this same technique to help members make more informed choices when deciding where to get care, empowering them to choose urgent care over the emergency room when appropriate, according to Walsh.

“Our informatics team identified common behaviors of members who had used the emergency room when urgent care would have been more appropriate-and less costly,” she says. “We then used different content and images to best resonate with those specific audiences. Through this social media and direct-mail campaign, we saw an 18% reduction in unnecessary emergency room use. In fact, six out of 10 households actually used the urgent care location suggested.”


Tracey Walker is content manager for Managed Healthcare Executive.

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