Healthcare Benefits – The Answer is Value

The healthcare conundrum continues to be viewed from the lens of cost and access. What if this is the wrong perspective?

The healthcare conundrum in our country continues to be viewed from the lens of cost and access. Contain the rising costs or provide greater access to care? This perceived conflict has resulted in virtually every meaningful healthcare policy change being viewed as failing one or the other.

What if the debate between cost and access is the wrong perspective to begin with? What if the true measure of healthcare efficacy is value? Does looking at healthcare policy through the lens of value allow us to get over this seemingly unbreakable tie-breaker and allow us to focus on what truly matters?

Given that 49% of healthcare coverage and 82% of healthcare costs in the US are employer-sponsored, is it time for the healthcare policy debate to be constructed in a manner that is impactful to employers and the end consumer: the patient?

If we shift our focus, the next question will be: how do we define value in the complex schematic that is employee healthcare benefits? We don’t need to look much further than a construct that was seeded within healthcare more than 12 years ago.

In 2008, the Institute for Healthcare Improvement formally launched the Triple Aim initiative, designed as a way to help healthcare organizations improve the patient’s experience (quality, access, and outcomes), while reducing the trajectory of cost increases. Triple Aim included Population Health, Experience of Care, and Per Capita Cost. Later, the industry added a fourth focus area to acknowledge the role of healthcare workers in delivering value, with an emphasis on staff satisfaction – and the Quadruple Aim was born.

Today, we’ll focus on the initiative’s initial foundation. Let’s discuss how the Triple Aim could be especially beneficial in the employee benefits arena, as employers evolve into buyers of value-based healthcare solutions.

1. Population health – Putting healthcare back in healthcare benefits and ensuring that clinical appropriateness trumps any and all financial considerations. To do this, there must be a willingness to disrupt the suboptimal and tired condition-based orientation of clinical programs. We must look beyond a person’s most dominant diagnosis and assess their clinical risk by also understanding their comorbidities and socioeconomic factors. A healthcare strategy with any real shot at success requires recognizing that each employer has a uniquely different employee population that requires a tailored clinical strategy based on a combination of current clinical, socioeconomic, and predicted risk.

2. Experience of care – Paying for increasingly expensive benefits with subpar service and reduced access should be unacceptable. Yet, that continues to be the norm. Healthcare benefits done right provides greater access to needed care, when it’s needed. High-risk members with chronic conditions should receive a differentiated level of service to help navigate diagnoses without blowing the employer’s healthcare budget. The patient is supposed to be at the center of healthcare as the ultimate consumer, and really can’t afford to be an afterthought in a B2B decision-making paradigm.

3. Per Capita Costs – Why should service suffer while costs continue to go up? Why are benefit providers calling the shots in this entire dynamic rather than the employer that purchases the services? What if employers demanded a pay-for-performance model in which benefit cost increases impacted the benefit providers financially? Wouldn’t that force the healthcare benefits industry to adjust? A truly aligned and value-oriented model is one in which employer outcomes are directly related to benefit provider income.

Drawing parallels to each of the initiative’s core focus areas enables employers and plan sponsors to break down what can often be a complex evaluation to ensure they are truly deriving value from their benefits. If done right, this requires a rejection of an ‘it’s always been done this way’ mindset. Healthcare benefits shopping must be the driver of the next generation of transformation in our healthcare system. For this to happen, employers must demand change, and tell their benefit providers that the cost, access, and service tradeoffs of the past are unacceptable. When employers put a stake in the ground and hold benefit providers responsible for solutions that live up to the foundational principles of the Quadruple Aim, we may finally see value-based healthcare live up to its promise.


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