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Strategies for Designing Consumer-Centric Health Plans

By Chuck Green

November 12, 2018 - The Health Care Transformation Task Force recently released a new set of guiding principles to help healthcare industry leaders and policymakers better integrate consumer needs into benefit design.

The goal of the task force, a consortium of leading healthcare payers, providers, purchasers and patient organizations, is to accelerate the industry’s move to value.

“Incorporating the holistic consumer perspective into health insurance benefit structures is a critical step toward a true value-driven health care system,” said Fran Soistman, executive vice president, Government Services at Aetna and chair, HCTTF. “Our hope is that these principles will help inform the health care community and help drive toward the goal of people-centered, value-driven health care.” 

“This work is truly a product of HCTTF’s unique collaborative, multi-stakeholder perspective,” added Jeff Micklos, executive director, HCTTF. “It reflects an ongoing commitment by our payer, provider, purchaser, and patient advocate members to find the best ways to engage consumers from the beginning of their interactions with the health care system.”

Each principle consists of specific elements that provide clear direction on how best to engage individuals in the benefit design and care delivery process. “This guidance offers a welcome new perspective on how to put consumers at the center of benefit design,” remarked Katie Martin, vice president for Health Policy and Programs, National Partnership for Women and Families. “It strikes a thoughtful balance between consumer needs and industry value priorities.”

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1. Payers, providers, and purchasers should utilize modernized ways of obtaining consumer input.

They should also offer effective decision-making support tools that help facilitate greater partnership with consumers in navigating the healthcare ecosystem, including but not limited to obtaining information, coverage, engaging in care, reporting outcomes, and paying for services.

Payers, providers, and purchasers should hone in on modern methods to obtain input from consumers and offer effective decision-making support tools to foster a stronger partnership with consumers. That relationship would help them navigate the healthcare ecosystem that includes, among other things, obtaining information, coverage, engaging in care, reporting outcomes and paying for services.

2. Payers, providers, and purchasers should collaborate to create high-performance networks that enable people-centered care. Value-driven networks should directly incorporate input from consumers in their design, including focusing on desirable outcomes and consumer experience.

A high-performance network incorporates cost, utilization, and multi-stakeholder accountability while emphasizing higher quality. Examples of effective quality metrics include patient-reported outcomes, 360-degree peer feedback for physicians and established measure sets such as HEDIS.

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Furthermore, cost and quality data, patterns of provider use, adequacy standards and preferred care delivery settings can help further pinpoint consumer preferences and network redesign. Meantime, to promote informed decision making and help consumers easily identify relevant care programs that address those needs, network design should reinforce upfront transparency around cost structure and pricing, while health plans, providers and purchasers need to design high-performing networks that shore back health disparities by making sure members can access culturally competent and high-quality providers.

And it doesn’t stop there. By doing things like establishing maximum wait times, networks can enable consumers to immediately access the complete range of required services – including specialists and subspecialists. On top of that, directories should be updated regularly and financial guardrails, such as reduced cost sharing and benefit level exceptions (e.g., the waiving of tiering requirements) should be created to protect medically complex patients in need of external experts.

Additionally, medical coverage services should be coordinated with behavioral health services to adequately address the complex interplay of medical and behavioral health conditions, and organizations should strongly press for additional flexible privacy standards aimed at ratcheting up the level of coordination. 

3 Organizations should develop multimodal communication strategies that will simultaneously educate and engage beneficiaries around payment and care delivery options

Payers, providers, and purchasers should work in tandem to guarantee consumers obtain the information and education paramount to their ability to weave their way through challenges payment responsibility can pose and thoroughly understand their benefits. What’s more, individuals and providers should be able to easily review and compare service costs so that they can reach decisions about care, such as at the point of service.

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4. Value-based arrangements should include explicit accountability for member experience and outcomes

Collectively, payers, providers, and purchasers should ascertain members’ balance of responsibility, which could vary based on value arrangement and consumer type. And payers should — at the very least — be held responsible for the experience of members at the enrollment and payment stages, while provider accountability should fall within the stage of care delivery. Meantime, consumer shared decision making should be folded into care delivery.

5. An ideal network and benefit structure centers primarily on the needs of the individual, balanced with the needs of the purchaser, payer, and provider. Elements of benefit design should be conceived through the consumer perspective.

The best benefit designs should shift from plans fueled by high high-costing and coinsurance to extract the incentive from service use over to designs that motivate beneficiaries to search — when the place and time are right — for appropriate preventive, diagnostic, acute and maintenance care delivered by high-quality providers.

Rather than penalties, value based insurance design should be leveraged to motivate healthcare consumers. What’s more, consumers should be compelled to cultivate a relationship with a primary care provider and be provided with the ability to opt in to high performance networks, while a benefit design that evolves around the consumer should accentuate the importance of improved care coordination and a cut in services replication.

Another recommendation: Cross-country partnerships with retail and tech organizations should become an option among payers in order to harness top line data on aggregate consumer preferences and purchase patterns for person centered design.

6. Organizations should operate systems that promote the use of people-centered Health IT. Consumer interfaces should prioritize simplicity, clarity, and transparency. Consumers should have on-demand access to meaningful information that helps them understand their health and care, as well as directly supports informed decision-making.

Interfaces should help steer consumers toward high value products and evidence based decisions, while designs periodically should be updated to reflect today’s consumer needs. The consideration of elements like color and screen placement and language/literacy and consumer archetypes and how appropriate they are among some. • And encouraging messages should be used to prompt consumers to become better informed about various factors, such as their choice of physicians.

Consumers also should be provided two-way access to their own health data, along with the ability to access and share their health record and supplement that record with personal data like health history, preferences, outcomes and care goals. Additionally, sharing of clinical data should incorporate intelligent design features that abet the effort to educate and engage consumers, like minimizing the unneeded visits and calls.

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