Purchasers are demanding a better health care experience for their members—at a lower cost.
Competitive plans will be defined by their ability to provide and manage an effective, low-cost network. To succeed, plans must actively influence where, when, and how members receive care.
Keep reading below for a preview of our latest research on how to transform your business.
1. Reducing network costs through restricting the “wrong care” is reaching diminishing return
Health plans have traditionally managed network costs by restricting the wrong use of care—lowering rates, narrowing networks, and adding performance accountability. But these strategies are too slow and finite to keep up with growing health care costs.
2. Plans need to reverse their approach to network management: encourage the right care rather than restricting the wrong care
By weeding out non-preferred providers, plans have actually made it harder for members to access our network cost-effectively. Complex cost-sharing structures confuse member decisions. Fewer options can mean delays to necessary care. To lower medical spend in the long term, plans must instead flood the market with alternative, low-cost care options and add new, convenient access points to them.
3. PCPs are an untapped avenue for delivering affordable specialty care
Members’ strongest relationships are with their PCPs, but these physicians offer limited services. Health plans can upskill PCP knowledge and skills by investing in telehealth services that enable PCP consults with specialists for management of complex member needs.
4. Members choosing their own specialty care—and the work that comes with it—guarantees them a miserable experience
Members must work hard to make good health care choices: they need to identify appropriate providers, schedule appointments, and calculate out-of-pocket costs. Only those who spend hours doing it are successful and most don’t expend that much effort. Once members complete all this work, they are basically trained enough to be a health plan employee—and extremely frustrated by the process.
5. The same plan member experience strategies that succeed in primary care are failing in specialty care
Plans are equipping members to make rational health care decisions with literacy training, transparency tools, and provider directories. Members feel empowered to seek desired primary care experiences but they turn irrational when they experience new, acute care needs.
These emotionally vulnerable members struggle to make the complicated decisions required in specialty care and plan empowerment messages seem aloof rather than supportive.
6. Poor specialty care experience wastes 5-15% of total plan medical costs
Specialty care navigation impacts not only member experience but also plan medical costs. Plans waste 5-15% of total medical costs every year on inappropriate specialist utilization from over-utilization, out of network specialists, ED utilization, and deferred care.
7. HDHPs make it more difficult to identify high-cost members, but the ability to identify high-cost members is essential for safe plan growth
Members with high-deductible health plans (HDHPs) defer necessary care in the short term, but may become sicker and more hospitalized in the long-term. New members—especially those with HDHPs—test the plan’s identification capabilities, since the plan won’t have historical claims it can use to identify a potentially high-cost member.
Plans who grow without the proper identification capabilities will underestimate the cost risk of their members and miss opportunities to curb avoidable spending.
8. The fight to identify members can’t be won in isolation—plans need a variety of potential plan allies who have information about members
Census Bureau and consumer data, when meshed with data plans already have on members, is a powerful tool to fill data gaps with new members. In addition, organizations who interact frequently with members, such as schools and food banks, can serve as on-the-ground, in-the-moment eyes to identify members.
9. To increase the collection rate of critical information, plans must sharpen their surveys to the fewest questions necessary to identify members
Members don’t complete traditional HRAs because they take too long to complete and are filled with jargon. Plans should take a red pen to the HRA and cut the questionnaire to no more than ten essential, predictive questions. Plans should also equip customer service reps with one short question to identify members requiring plan intervention, taking advantage of every member touchpoint.