HBR: What the Insurance Industry Can Do to Fix Health Care

PHI driven implementation of value based health care…

https://hbr.org/2014/12/what-the-health-insurance-industry-can-do-to-fix-health-care

What the Insurance Industry Can Do to Fix Health Care

DECEMBER 23, 2014

Health insurance companies are uniquely positioned to save the day in our ailing health system. Yes, you heard me correctly: health insurers.

Health insurers — or “payers” — are reviled nearly universally. Confused by “explanation of benefits” forms and denials of coverage and frustrated by rising deductibles, co-pays, and costs of care, consumers rank their experiences with health insurers below those with cable companies and internet service providers. Physicians and other care providers — who are constantly negotiating price of services and filling out piles of paperwork — don’t like payers much either.

All this makes insurers unlikely heroes. But we need someone to cut through the complexity of the current system, demand true value from providers, and create better options for consumers. Insurers increasingly look like the folks who can do the job and reinvent their business at the same time.

How? They can use their market power (they direct the bulk of health care dollars) and understanding of different consumer segments to create innovative products, services, and partnerships that address consumers’ needs. In the process, they can help move us all toward a low-cost, value-based health care system. Here are some specific ideas on what payers could do:

Act as true partners to value-based providers. Most payers today are piloting new economic models that pay providers not for the services they provide but for the value they create. Most, however, are neglecting a key opportunity: helping providers change their operating model. To succeed in value-based care, providers need data, analytics, smart clinical-care teams, and managerial support. Insurers are well-positioned to provide all this. They can also help providers become more efficient and assist them in navigating the tricky financial transition from fee-for-service to fee-for-value economics. Most important, insurers can help the very best provider organizations succeed by using them as the core of attractive, competitively priced insurance products.

Offer options for low-cost, convenient care. One area of waste in health care is the use of physician offices and hospital emergency departments to treat minor conditions such as sore throats, urinary infections, and allergies. Payers can make it easy for their members to get care 24/7 in more appropriate settings by partnering with retail, urgent care clinics, and telehealth providers. They can also offer the data connectivity needed to keep the consumer’s primary care provider in the loop. Oscar, the New York health insurance company launched last year, received fanfare in the press over its sleek offering, which includes unlimited phone and video calls with physicians and a “doctor on call” service that provides prescriptions by phone or e-visits. A number of retail pharmacy chains are also actively pursuing retail health and wellness clinics in stores to boost growth.  Walmart has been piloting low-cost care clinics offering a $40 office visit that could dramatically reset the cost bar if scaled broadly.

Cover new wellness- and prevention-oriented treatments. Such options can serve as effective adjuncts to traditional benefits and encourage the trend toward more self-care. Aetna, for example, has offered mindfulness and yoga training to 6,000 of its employees. Its research shows that lower employee stress improved productivity by 69 minutes per week and gave an 11:1 return on investment. Similarly, articles in The New York Times, TIME, Scientific American, JAMA, and The Huffington Post cite growing evidence of the efficacy of meditation programs.

Explode the PPO model. Today the gold standard for health insurance is a preferred provider organization, a huge collection of doctors assembled to provide something for everyone but no special benefit to anyone. Insurers can do a better job for consumers and create real value by developing hassle-free mass customization. In this new model, consumers can choose from lifestyle-based curated options that offer trade-offs across risk level, health-savings options, primary-care models, alternative networks, network breadth, coaching and navigation programs, rewards programs, contract length, and incentive structures. Transparency tools and crowd-sourced reviews will spotlight value and multi-modal coordinated care delivery (think care teams that seamlessly work with telehealth providers, health coaches, and retail clinics) will help cut costs considerably. Consumers will be able to trade their own health engagement into benefit dollars and rewards that they can use seamlessly. While true à la carte insurance customization is not yet a reality, private exchange platforms are starting to provide a stepping stone to get there. For example, Maxwell Health, a new private exchange platform, presents a beautiful interface with lifestyle-focused packages that make product selection simple and tailored for you.

Sell convenience and personalized service. Most health care could hardly be less convenient. Now that consumers have unprecedented purchasing power (rise of public and private exchanges) and bear unprecedented costs (mounting high deductibles and premiums), they expect iPhone-like service. There is tremendous opportunity for payers to make the health care experience simpler and more supportive with online appointment scheduling, clear data and reviews, personalized suggestions, navigation apps with predictive decision support, reward programs, peer-to-peer support, and many other tools. Making the consumer experience better is smart for payers too. They can build stickier consumer relationships and generate new opportunities to address consumers’ growing health and lifestyle needs.

Power healthy behavior change. Some 50% of the determinants of health are driven by lifestyle and personal behaviors. Changing people’s behavior is a tall order but is necessary to improve health care. There are already examples of innovators that are succeeding, such as Omada Health with weight loss for pre-diabetics and Zipongo with healthy eating. We’ve only begun to deploy behavioral science, advanced wearable/monitoring technologies, and machine learning to understand the behaviors and motivations of different groups to predict and prevent acute events and connect people with the solutions that work best for them.

Serve as the bridge between new tools and consumers. In the first half of 2014,venture capital investment in digital health grew by 176%, spawning new consumer-centric companies with interesting approaches to consumer health. But there’s a chasm between these unscaled point solutions and the consumers who could use them. Payers can bridge the gap, using Amazon-style analytics and personalization to better understand consumer types and then connect them at the right place and time to the best-suited offerings. Better yet, payers don’t need to build the bridge themselves: A growing set of powerful consumer-engagement platforms (e.g., WellTok and Optum’s Rally) are moving along this path.

Payers have economic incentives to do everything I’ve described. The Affordable Care Act puts limits on the margins they can earn from their traditional business (Oliver Wyman estimates payer margins may shrink by a third), and an evolving marketplace means that they will face significantly more competition — from each other, health care providers, and new entrants that see an opportunity to capture growth in a $3 trillion market. The options I’ve described would let payers move into non-regulated markets and potentially generate revenue from discretionary consumer spending — a growing pot of money they have not accessed much.

Can they win consumers over? One advantage of being in an industry people don’t like is that there are many opportunities to pleasantly surprise the consumer. The good news is that the things that will make consumers happy — more convenience, customization, support for doctors, coordination of care — can all contribute to attractive new business opportunities while making the health care system more efficient, effective, humane, and sustainable.


Sukanya Soderland is a partner in Oliver Wyman’s Health and Life Sciences practice and a leader in the firm’s Health Innovation Center.