Growing the Value Proposition of Commercial Health Plans | Geneia

Growing the Value Proposition of Commercial Health Plans

March 28, 2017
Kevin Rill, Head of Solutions Architecture

 From claims adjudicator to objective consultant and trusted guardian

It is clear,” states research giant, Gartner, that “healthcare payers’ business models must advance in 2017 to match the aspirations of industry CEOs.” These aspirations revolve around a “more valuable market position … focused on the value delivered to their customers.”


I wholeheartedly agree.


The value proposition of the traditional commercial health plan is changing. Increased competition as more healthcare organizations offer insurance products, market uncertainty, declining margins and increasingly savvy consumers who understand healthcare purchasing are putting downward pressure on health plan value. Health plans still focused on fee-for-service reimbursement and the claims adjudication mindset are all but guaranteed to fail.


To stay competitive and relevant, health plans must leverage – and strategically augment – existing analytical capabilities to accelerate their shift to consumer-focused, high-value, cost-controlled care delivery. As the delivery of value-based services overtake the status quo, health plans realize:


  • Flattening of the cost curve and reduced medical expense over time
  • Higher quality ratings, which are increasingly important in a competitive landscape
  • Increased member engagement and satisfaction


Trusted Stamp Advisor



Further, health plans earn and enjoy a higher degree of trust from members as they embrace and advance the vision of becoming a true guardian of member health.


Delivering value-centric care and becoming a trusted advisor hinges upon recognizing opportunities and leveraging resources (people and technology) to turn them into meaningful actions -- actions that strengthen the delivery and payment sides of the healthcare equation for members.


Consider this: for years, health plans have known which providers and facilities provide the highest-value services. Legacy attitudes and contracts, however, hold them back from steering members toward these high-value services. Long-standing relationships with large care delivery systems and a perceived need to give members a ‘choice’ are two such inhibiting perspectives. Sometimes, health plans believe they have a cost advantage with specific entities, regardless of the quality of care they deliver -- a belief that deters them from taking a strong stance on quality.


The opportunity exists in this situation for health plans to advance their business model and support leadership vision. For example, successful health plans use analytical tools to gain the deepest possible understanding of the patient-member experience and how that experience evolves over time. This understanding, combined with existing knowledge about where to obtain the highest-value services, enables health plans to strategically and intelligently consult, steer and reward the utilization of high-value services. 


When health plans commit to this type of strategy, low-value care providers are indirectly affected, sometimes to the point of change or extinction. At the same time, high-quality utilization increases. As a direct result, health plans can share financial rewards with members in the form of reduced premiums and with providers in the form of shared savings, thus generating a concrete win-win-win for health plan, provider and member while improving quality ratings and continuing to spend 80 to 85 percent of each premium dollar on medical expenses.


Population health solutions like the Theon® platform, use analytics to deliver unbiased, objective insights to help health plans identify, understand and communicate high-value services to each member for their unique healthcare needs. These data-driven insights help health plans take actions that favor high-value care across the full care continuum.


By relying on unbiased data, the Theon® platform helps health plans set aside legacy thinking that inhibits growth. Freely shared, objective information promotes relevancy through transparency and guidance for patients, physicians and health plans. This, in turn, promotes effective partnerships, better outcomes and higher-value services. Over time, and with continued effort, population profiles change for the better.


Over time, members will come to realize their health plan has evolved significantly from claims adjudicators to a trusted partner, genuinely invested in improving their health in collaboration with high-value providers. This evolution of consumer perception is the foundation of growing the health plan value proposition.


I think it’s time to ask ourselves why value-based healthcare is such an original idea when we purchase almost everything else in our lives based on value. Toasters, cereal, televisions, automobiles, restaurant meals … we purchase nearly everything based on the best performance/cost perception. So why is healthcare so different? It’s because traditionally the purchase of healthcare and insurance hasn’t included necessary and transparent information about cost, quality and overall satisfaction – the essential components for measuring value.. I look forward to discussing this in my next blog.


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