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Five Changes Health Plans Need to Make Now

Les Masterson, for HealthLeaders Media, May 12, 2010

Over the past three issues of HealthLeaders magazine, I wrote a three-part series looking at the health plan of 2020. I examined possible payment models, benefit designs, and member relationships in 10 years. 

I started writing the series when health reform looked iffy at best, but with or without health reform, insurers need to prepare for a very different world by 2020.

Healthcare costs and the employer-based health insurance market are not sustainable in the long run. Forcing members to shoulder more of the costs isn't going to work.

Eventually, we will reach a tipping point in which it will no longer make economic sense to buy health insurance and health insurers need to make sure they don't reach that tipping point.

Here are five changes health insurers need to make now in order to survive in 10 years:

1. Invest in technology. A no-brainer, right? Some insurers haven't realized this yet and are falling behind. With meaningful use an important issue for providers, insurers need to help them implement technology, such as EHRs and online portals. Insurers can benefit by creating computer networks that allow providers to have information about their patients, while also allowing the insurer with more clinical information from the provider. Insurers should also invest in self-management tools that are targeted to the individual and allows the person to improve his or her health with assistance—if needed—from a call center nurse or physician depending on health status.

2. Hire consumer experts. The individual market is one of the few growth areas for health insurers and this will only continue as most Americans will be required to have health insurance. The market is changing and insurers will have to switch focus. No longer will they be able to deal mostly with employers and benefits people. They will have to reach down to the individual level. As a way to get a better view of consumers, insurers should explore other consumer markets to see how they connect with customers. Step one is hiring some of those experts to help implement new strategies.

3. Design benefits that reward value and make sure you have doc buy-in. As I wrote in part two of the series, innovative health insurers and employers understand they cannot continue to pass more costs onto the individual. One other avenue is to create tiered health plans that reimburse doctors based on type of care and its value. Health insurers and employers should not design these plans in a vacuum. They need to get physician buy-in, which means having doctors help design the programs.

4. Design benefits for the individual. Rather than simply creating a handful of plans, such as a PPO, HMO, and POS, UnitedHealthcare recently created a health plan designed specifically for diabetics and prediabetics. Using aspects of value-based insurance design, the insurer is lowering or removing copays for value-based services and medications for members in those plans. As everything becomes more individualized, it only makes sense that health insurers will create plans that focus on the member.

5. Collaborate with providers to get more data. Claims data serves its purpose, but the holy grail for health insurers is tapping into providers' clinical data. This is beginning to happen, but providers understandably are leery about how that information will be used. As quality contracts become more common, health insurers will have more access to clinical information, but the key is how they use it. This information should not be used strictly as a way to reimburse (or not reimburse) for providing a certain level of quality. Insurers need to also create processes and analytics so the information can be used to help care management programs.

Having the clinical and claims data together, health insurers will have a more-rounded view of the patient/member. So, rather than waiting a month or two or three for claims information that may or may not have enough data, insurers would have more specific information about the visit. They must also understand they have to share claims data and pay more promptly to providers through better technology, such as real-time claims adjudication.

Insurers are trying to figure out how to do business in a post-health reform world and there are no guarantees. But by taking these five steps insurers will be prepared for whatever the future has in store for them.


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Les Masterson is an editor for HealthLeaders Media.

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