New Marketplace
Clip
Resolving the Payer-Employer Disconnect (03:03)

What’s keeping payers from becoming health brokers? What stands in their way?

“We need to collaborate more with our employer partners, and we need to sit down and think about reform of how we pay,” says Lynn Garbee, Cigna’s Senior Director of Reimbursement and Collaborative Care. “There’s a lot of room for us to really transform, to use the data, but I’ll just be quite candid that most people who work in health plans have worked in health plans for decades. We need more outside-in thinking.”

NEJM Catalyst New Marketplace Theme Leader Leemore Dafny asks Garbee about collaborating with employers to get them to agree with reference pricing, where a price is fixed for a certain procedure or therapy and then the member is exposed to any costs beyond that price. “Are you saying that you can’t get [employers] to come to the table, or they just don’t care enough about controlling the spend to deal with the education that is required for their workers, and the upset that it can cause?”

“I don’t think employers are willing to do a reference-based price in a lot of cases because of that exposure that they would have on the upside,” says Garbee. But she notes that payers are seeing more efforts at reference-based benefits, which place deductibles or coinsurance on top of the allowance and allow that coverage for employees.

“Just thinking differently about things like social determinants, that would change how they pay for health care, to really maybe get a better outcome and make it more affordable,” says Garbee. “We haven’t gotten that far yet in discussing that with our employers. And I think we as an industry suffer from our insular thinking — thinking in just a health care [kind of] way.”

Bob Galvin, CEO for Equity Healthcare, adds, “No other country is asking its citizens or employees to be this smart about the kind of health care that they choose. It’s not like this is easy to do and you can just do it.”

Galvin recalls that at employee focus groups he conducted on clinician quality and choosing clinicians, the number one complaint was, “I’m so confused; I need a navigator.” They weren’t concerned about choosing a doctor, but they didn’t understand “what that bill means, I can’t get the doctor’s office to call me back, etc.,” says Galvin. “And if you solve that need for me, I will be such a grateful employee.”

“We’re a little bit disconnected with where people outside of this room and this stream are. It makes those kind of things tough to do,” he says.

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

Hospital Readmissions Reduction Program (HRRP)

Medicare’s Hospital Readmissions Reduction Program was established by the ACA to combat excessive and costly readmissions. Learn about HRRP penalties, criticisms, and strategies to reduce readmissions.

Conceptual Framework for Evaluating Specialty Care Partnerships

How to Engage Specialists in Accountable Care Organizations

Should an ACO insource or outsource specialty care? Here’s a framework to help leadership decide.

Illustrative Examples of Health Policies, Possible Goals, and Relevant Evidence Base

Evidence-Based Health Policy

Having a clear framework for characterizing what is, and isn’t, evidence-based health policy is a prerequisite for a rational approach to making policy choices.

U.S. and Canadian Prices of Some Generic Drugs with U.S. Prices That Recently Increased by 1000% or More

The Price of Crossing the Border for Medications

The health and safety risks faced by the many Americans who cannot afford medications necessitate consideration of alternative strategies to provide less expensive medications.

Economic Investment and the Journey to Health Care Value — Part III: Health Care Purchasers

Early successes suggest that value-based purchasing programs can both transform employer-based health care and have a powerful and lasting impact on the economic strength of U.S. businesses.

Single-Payer Health Care Is the Favored Outcome of Future Payment Reform

Survey Snapshot: Deep Frustration with the Current Payment System

Many NEJM Catalyst Insights Council members are frustrated with the pace of value-based payments and expect single-payer health care to gain traction — though maybe not soon enough.

Value-Based Payment Models Payer-Provider Contracts Value-Based Arrangements

Economic Investment and the Journey to Health Care Value — Part II: Health Care Payers

Payers’ broad scale of investment in value-based arrangements makes a compelling case for the importance of sustained efforts to identify effective value-based payment models.

Four Principles for Navigating Payment Reform

The changes needed in health care are happening way too slowly. Health care stakeholders must insist on value in what they pay.

Economic Investment and the Journey to Health Care Value — Part I: Health Care Providers

Early evidence suggests that value-based payment and care delivery can transform our health care system, but providers must increase the momentum for this positive change.

Shift Toward Value-Based Payments in the Industry and at Organizations Is Accelerating

New Marketplace Survey: What’s Next for Payment Reform?

As health care reform struggles to gain traction legislatively, health care professionals report that payment reforms continue to move forward at a moderate pace, and indeed are essential to achieving the Triple Aim.

Connect

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

Learn More »

Topics

Value Based Care

179 Articles

Personas of Leadership in Value-Based Care

The deliberate nurturing of specific types of leadership personas seems to be a critical factor…

Survey Snapshot: Seeing Progress in Transparency,…

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

Aggregators, Innovators, and the Resurgence of…

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

Insights Council

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

Apply Now