New Marketplace
Talk
Health Plans of the Future Are Win-Win-Win (11:05)

“Health plans are a force to transform health care in the United States, to create a productive workforce that’s vibrant and high performing, and to help provider partners be successful in value-based arrangements,” says Lynn Garbee, Senior Director of Reimbursement and Collaborative Care for Cigna.

How? By taking advantage of what they have to create value that other stakeholders do not: their size and position in the ecosystem — hundreds of thousands of providers, hundreds of accountable care relationships, millions of consumers, and thousands of employers across many products and geographies.

Aligning incentives is the first step, and it’s already happening with ACO relationships, specialty collaboratives, and pay-for-performance arrangements. “In each of them there’s a win-win-win,” says Garbee. “The physician and the employer are rewarded when there’s a good outcome for the patient, we’re creating engaged and motivated patients/consumers through our product design, and we’re connecting those consumers, those individuals, with our highest-performing providers.”

Next, health plans have lots of data about what makes a good provider group and can start segmenting them to make those connections. They can also give provider groups data they wouldn’t have otherwise, such as if a patient hasn’t filled their prescription.

Last is to invest where scale matters, in reimbursement automation as well as big data investments in analytics and reporting.

“But I’m going to contend that we can and we should be doing more,” says Garbee. “We can take these capabilities I just described to do more to transform health care. And we really need to do more to enable the success of those providers that are starting to take risk and are in shared savings arrangements, and really be the true guardian of an employer’s total dollars. To do that, we have to think differently about what insurance is.”

“We need to boost our big data with every other iota of data out there, much like other industries are doing, and become obsessed with connecting the perfect provider with the perfect individual. Be a matchmaker,” says Garbee. From there, health plans should use predictive analytics to expertly predict an individual’s health care journey and join all the products that patient is in to create a whole person —not just vision, dental, behavioral, or medical. This helps clinicians see data about gaps in an individual’s care that they wouldn’t see otherwise.

Health plans need to think differently about traditional covered expenses and consider “anything and everything that will help the productivity and the health of that patient,” argues Garbee. Leave the clinical decision-making to clinicians and let health plans help in taking care of social determinants that get in the way of a good outcome.

“What I’m saying is, we have to stop thinking about ‘insurance’ as homogeneous groups, but rather think about individualized and personalized bets that we can make based on all this data that we have and predictive analytics we can do to change the trajectory of a patient,” says Garbee. “Those smaller investments that can have a better outcome than the one that might be prescribed.”

Garbee provides a few examples:

  • Joe, with congestive heart failure, is given a $16 scale to help him manage his weight and avoid life-threatening complications — which would be an enormous expense for patient, employer, and risk-bearing provider. “We’re already seeing evidence that we can do little things like that to avoid bigger things,” she says.
  • Elaine, with multiple conditions and many doctors, attends an average 6-minute office visit, only understands half of what happens in that visit, and then goes home and forgets half of what she understood. Her employer pays $100 for that visit but only receives $25 worth. “In what other industry would that be OK?” asks Garbee. What if we gave Elaine a case manager on her phone that can travel with her, ask questions she doesn’t know to ask, offer additional information about Elaine’s life, and take notes?
  • Peter, who has just had a hip replacement from an orthopedic surgeon in a bundled arrangement, has 10 steps to negotiate at home, throw rugs in his bathroom, and no ride to his follow-up appointment. “Why wouldn’t we think about a hip replacement that’s about $30,000-$35,000 much like we do when we buy a car?” asks Garbee. “For a car, we put a warranty or a service agreement around it. We make sure that the tires are rotated, that the fluids are checked, but can we check to make sure that the throw rugs are taken out of the bathroom, that there is a bed on the first floor, that we can put an Uber in the driveway for Peter to get to his follow-up appointment?” Even better would be predictive analytics long before that hip replacement so that when Peter is in his PCP’s office and complains of hip pain, his PCP suggests yoga to help him avoid a hip replacement altogether.

The commonalities with each example? First, everyone is different. “We’re not going to have the same solution for every single one of our millions of consumers,” says Garbee. But, each example involves an incentive alignment. “We always are trying to make it so that the employer and physician are in a risk-bearing relationship and so that the patient, most importantly, is winning.” And by using predictive analytics, health plans can stop being confined to covered expenses and think more open-mindedly about what can help patients toward truly better outcomes.

The retail industry now has magic mirrors that, when customers go into a dressing room, know what clothes they have at home and can offer pieces to match. Why can’t we have something like that in health care? Why not match Garbee, who runs marathons, with a cardiologist who works with women who run marathons?

“That’s going to be the new insurance of the future, setting up all those win-win-win situations. We’re using predictive analytics to make small bets today to finance risk at a micro level to yield a macro, affordable, and high-quality outcome,” says Garbee.

“I do believe the answer is yes, health plans will transform health care through connecting motivated consumers with their perfectly matching high-performing provider, and then aggregating the small win-win-wins to maximize the success of the risk-bearing provider and minimize the expense of the employer. To really create a happier, high-performing, productive workforce.”

From the NEJM Catalyst event Navigating Payment Reform for Providers, Payers, and Pharma, held at Harvard Business School, November 2, 2017.

More From New Marketplace
Shachar01_pullquote value-based care fee-for-service fraud and abuse laws

Are Fraud and Abuse Laws Stifling Value-Based Care?

To realize the true potential of value-based care, we must update the underlying assumptions in our fraud and abuse regulatory system.

Porter02_SBUs and IPUs pullquote1

What 21st Century Health Care Should Learn from 20th Century Business

Just as there is no such thing as good marketing or good manufacturing, there is no such thing as good primary care — it completely depends on how that care is tailored to meet the needs of patients with a particular medical condition.

Missouri Show Me Health Plans Cost Calculator for Health Insurance Enrollment screen shot - health insurance education

Facilitating Health Insurance Enrollment in an Uncertain Environment

Lessons learned from five years of open enrollment in Missouri.

Birkmeyer02_pullquote - national physician practices NPPs

Aggregators, Innovators, and the Resurgence of National Physician Practices

A perspective on the growth of NPPs and the ideological divide between for-profit and nonprofit providers.

Hospital-based ACOs Key Capabilities Are Different Based on Level of Risk

Hospital-based ACOs Face Challenges in Tracking Performance Indicators

A focus on bundled payments for specific episodes of care — versus the broad changes required in an ACO model — may be a more effective method for ACO participants to develop capabilities required to measure utilization, cost, and revenue metrics.

Medicaid Referral to Specialist by the Numbers without eConsults

Can eConsults Save Medicaid?

How eConsults unlock medical expertise for the underserved.

Transparency Can Improve Both Quality and Cost of Care

Survey Snapshot: Seeing Progress in Transparency, but the Quest for Value Continues

NEJM Catalyst Insights Council members agree that despite the challenges and caveats, transparency efforts are essential.

Growth in alternative payment models shared savings shared risk bundled payments population-based payments

The State of the Evidence on Payment Reform

Despite some successes among the many efforts to execute value-oriented payment models, the lack of rigorous independent research studies impedes robust progress.

University of Utah Health Buzz Survey Report Cost of Care and Physician Responsibility Out-of-Pocket Costs

Buzz Survey Report: Cost of Care and Physician Responsibility

An independent NEJM Catalyst report sponsored by University of Utah Health on how practicing clinicians and health care leaders view health care costs.

Donald Berwick Melinda Buntin Patrick Conway Raymond Vara Edward Prewitt head shots IHI forum panel on health care policy

Signal or Noise? Navigating Health Care Policy — Part 2

A discussion from the Institute for Healthcare Improvement National Forum. Part 2 of a two-part series.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Value Based Care

181 Articles

Are Fraud and Abuse Laws Stifling…

To realize the true potential of value-based care, we must update the underlying assumptions in…

What 21st Century Health Care Should…

Just as there is no such thing as good marketing or good manufacturing, there is…

Disrupting the Health Care Landscape: New…

Traditional boundaries are disappearing in health care. Unlikely partners such as CVS Health–Aetna are teaming…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now