Value-Based Benefit Plan Design Can Produce Better Results, If We Can Make It Happen


“With some well-known algorithms, it’s not difficult to stratify a population based on risk and get providers to spend more time with patients at higher risk,” says Dr. Stan Schwartz. (Photo: Shutterstock)

Providing quality care at an affordable cost is the goal of everyone in the health system. Achieving this elusive goal, however, is a never-ending challenge.

“We have created a health care system where the average person with health insurance often cannot afford to go to the doctor,” said Dr. Scott Conard, medical director of the National Alliance of Coalitions of ‘health care buyers. “The average person has $ 400 to spend on health care for the month, and their deductible is $ 1,500. They are caught and may as well not have insurance unless it is a catastrophic illness. It is an absolute necessity for businesses to find a way to navigate through this.

Related: Has Value-Based Care Hit a Tipping Point?

“How do we get back to people paying attention to the cost of care? What’s the smart way to do it in today’s market? “

Conard hosted a webinar on June 3 in which several experts addressed these and other difficult questions. Dr. Stan Schwartz, president and CEO of Well OK in Oklahoma, recommended taking a closer look at what value really means.

“We usually talk about value as quality divided by cost, but it’s more than that,” he said. “High-quality, uncomplicated surgery is of no value if it doesn’t need to be done. Many of our quality indicators do not take this into account. Safe and uncomplicated surgery that did not have the desired result is also not of value. Value must include doing the right science and doing the right thing for the right person at the right time and in the right place, which brings safety into the equation.

Technology is changing the way care is delivered and defined.

“You envision advanced primary care where guidance is intentional, systematic, and structurally integral to a practice,” said Schwartz. “The only question for the 21st century is whether it should be physical, virtual, digital or hybrid. I believe in a nursing home, but I’m not sure it should be brick and mortar right now. “

He urged basing the design of the plan on the needs of a specific population rather than on a single approach.

“Design your benefit plan with a thorough understanding of the health and risks of your population,” said Schwartz. “A majority of employees and members in their twenties is very different from an average age of 55. Using well-known algorithms, it is not difficult to stratify a population based on risk and get providers to spend more time. on patients who are at higher risk and prevent those who are at moderate risk from becoming at higher risk.

While insurance is essential, it is only one component of a larger strategy, said Dr Ray Fabius, co-founder and president of HealthNEXT.

“When you talk about value-based benefit design, you don’t want to limit your thinking to just the design of health care coverage or insurance,” he said. “You should consider a benefit design that eliminates, for example, medical homelessness, promotes advanced primary care, creates a comprehensive package that supports population health, and also envisions a much more holistic approach to supporting well- to be. “

For Fabius, a well-designed plan:

  • Keeps workers healthy;
  • Reduces health risks among the workforce;
  • Provides timely access to care when a person is critically ill, helping the subset of the workforce who already suffer from chronic illness cope and mitigate potential complications; and
  • For the 1% or 2% who have a catastrophic event, make sure they go to a center of excellence.

“The design of your benefits must take into account all aspects of well-being,” he said. “The workplace is an ideal setting for promoting a culture of health, safety and well-being. “

Even the best plan design will fail if not executed properly, said Dr Andy Baskin, independent consultant and former vice president of Aetna.

“As a plan sponsor, it’s important to understand what you expect from a value-based insurance design and what you’re actually getting,” he said. “There can be major differences unless you have someone who understands some of these intricacies. At the end of the day, it’s not just about saving money; it’s about improving care.

Amidst the high level of complexity, aim for simplicity.

“It’s important that your plan design is simple to explain and easy for members to use,” Baskin said. “If you don’t keep it simple, there will be inconsistencies and things will go wrong. Every time this happens, it reduces member trust, engagement, and participation, and you don’t get the results you want.

The key is to find the right balance between quality of care and cost.

“We don’t want to talk about a health care system; we want to talk about a health system, ”said Conard. “The best way to use America’s health care system is not to need the health care system. It’s about prevention and proactive intervention, not a reactive response to catastrophic problems.

While there are no easy fixes, Schwartz thinks it’s a goal worth pursuing. “Donald Duck’s nephews – Huey, Dewey and Louie – had a junior groundhog manual that answered to all the questions they asked themselves, ”he said. “But there is no manual on the junior groundhog for advanced primary care. It takes sweat and research to find it.


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