Market Forces That Change How Payers See Healthcare

Health insurers today are facing an existential challenge.

Partnerships and mergers between systems, insurers, and providers are gobbling up market share. The entry of large, powerful and traditionally non-healthcare organizations is threatening the payer business model. The scrutiny being paid healthcare in elections, including the overwhelming negative narrative in the media about a bloated system, is turning consumers against them. The market is changing rapidly, and payers know they must evolve or fall.

The first question health insurers are asking is what they can control. The quickest answer is the supply chain, which is why so many payers are getting into the business of providing care, not just paying for it. They all know the best, most effective care to provide is at the front end of the system: primary care.

When implemented correctly, an integrated primary care offering is the most effective addition to their business model. It adds value to their plans and establishes a competitive advantage to outside threats.

The case for primary care investment

In a traditional healthcare environment, providers are forced to focus on controlling costs rather than increasing the quality of care or improving population health outcomes. There is no incentive for members to use their plan with any frequency and, as a result, they often delay care until an issue is acute. This increases cost for both the payer and the member.

Related: Supplemental Support in Primary Care Can Improve Health

When payers control the design and delivery of primary care, they can offer greater access to all members from individuals, groups and those of Medicare Advantage, a best-in-class experience and true population health.

Having a dedicated provider and care team in one convenient place makes it easier for members to receive care, which, in turn, means they’re more likely to come in for regular visits rather than make expensive trips to urgent care clinics or the emergency room.

In addition, visiting the same provider consistently builds trust. Providers are able to proactively work with members to address the root causes of health issues before they require more intensive treatment.

Integrated primary care offers members greater access, an improved experience and better health outcomes. This offers payers a path to competitive advantage, differentiation in the marketplace and increased member satisfaction.

The right approach to primary care

Integrating primary care starts with understanding what’s important to a member’s health and creating a care model that meets the needs of the health plan population. Any effective primary care model should take into consideration the following factors:

• Accessibility to more providers, smart scheduling, low- to no-cost visits, convenient locations and no wait times.

• Time-rich appointments that allow members to be heard and providers to understand them beyond their symptoms.

• Primary care providers who have the time, support and staff to provide most of a person’s care-which in today’s system is being outsourced to specialists.

• Care coordination to prevent gaps in communication and treatment when specialty care is appropriate, including follow-up and integration into the member’s care plan.

• Empathetic listening that goes beyond prescriptive medicine, building connections and understanding of a person’s whole health.

• An informatics platform that identifies health risk opportunities and provides actionable insight into use.

• Professional health coaches who use the transtheoretical model of change to help patients improve their lifestyles and take ownership of their own health, possibly for the first time.

Design, adopt, or co-create

Investing in a partnership with an experienced primary care provider is the most effective way forward. There are three typical approaches and examples mentioned:

• Design your own care model and find a partner to operate it. A payer in a Midwest city designed a product that gives members access to primary care as part of their existing health insurance plan. They brought in an experienced partner who aligned with their vision for member experience. This approach works well for larger payers with significant in-house expertise.

• Adopt someone else’s care model. Smaller payers may want to adopt the model of a primary care partner who shares their vision for healthcare, rather than taking on the burden themselves. A payer in Nevada used this approach to quickly scale up a network of care centers to close access gaps and provide an improved care experience to members.

• Co-create a model. One payer in Washington State is co-creating their model with a primary care partner. This model will improve access with same-day or next-day appointments in an area where members often face a month-long wait for a simple office visit. They’ll also leverage the model to create an experience customized for their members’ unique needs.

It's easy to see why getting into care delivery is a growing trend amongst payers. By focusing on primary care and integrating it into their plans, payers increase member access to services and save on overall healthcare costs while raising value to members through better quality of care. It’s a smart strategy that differentiates them from their competition and positions them to preserve and even grow their market share despite external threats.

Ryan Schmid, is president and CEO, Vera Whole Health.