Many health plans are unsure about the future and are searching for answers. The news isn't always good.
Health plans are under constant pressure to be more affordable yet more efficient. But so much really depends on the members themselves. Health plans have their fingers crossed as they try to stem the tide of overwhelming healthcare costs, with or without help from Washington, says Jan Berger, chief medical officer for Silverlink Communications Inc.
Berger knows of what she speaks. Berger specializes in healthcare communications, and spends much of her time speaking with health plan leaders. Berger was previously senior vice president and chief clinical officer for CVS Caremark. She has been involved in the National Committee for Quality Assurance and serves as editor-in-chief of the American Journal of Pharmacy Benefit.
As the country debates healthcare reform, Berger says we have to look at where we are, and learn where we went. She recalls health plans and others were so convinced back in the 1990s that HMOs were the way to go and "we were Dr. Nos!" In that era, HMOs were quick to deny coverage, and the insurance jungle became a battleground between patients and insurers what should be covered or not.
Basically, as a health plan executive, you look at both ends of the spectrum and the idea is to bring in consumers with incentives to effectively change the health plan landscape and lower costs dramatically. It involves sorting through everything from the age-old issue of prescription drugs to the relatively new programs, programs such as value-based insurance design.
It's a risky proposition. But it can be done. It's as easy (or difficult) as throwing out the trash, Berger says. (We'll get to that later).
The pharmaceutical aspect of healthcare has really been lost in the shuffle in the healthcare debate. But patients are continually facing significant out-of-pocket medication expenses that Berger says will lead to more "non-adherence"—patients not paying attention to what they should be taking"—no matter what physicians want, no matter what health plans want. Eventually one of every two medical consumers become non-adherent in using their medicine within 12 months of medical therapy, according to Berger's figures. The result is significant because there are often severe setbacks, or as Berger puts it, "adverse impact" on the individual's health, and more costs for health plans.
As the Medicaid rolls increase, it will be important "that a primary care provider and others work to educate and support the patient to assure they will have the correct medication to maximize the efficacy, and therefore, value of the new medications," Berger says.
Having participants, plans, hospitals and physicians working together is a big part of the value-based insurance programs that Berger and other proponents see as the wave of the future to keep costs down. The idea is to encourage better use and compliance of high-value health services and adjust copays as a result. The plan also places more reliance on wellness programs to reward employees who help themselves.
Berger has been a supporter of the American Association of Preferred Provider Organizations, which has recommended using value based health care to improve results for payers. In a 2009 white paper, the AAPPO noted, "Successful [value-based] programs use the levers of information, motivation, and financial incentives to encourage new behaviors" such as:
The full-blown scope of value-based insurance has yet to be discussed on Capitol Hill, Berger contends. "Value-based insurance was one of the areas that was discussed during the healthcare debates. It was focused mostly on medications," she says. "At this time, Medicaid and Medicare have limits on the incentives that can be used in value-based insurance design."