Payers who want to affect the change needed to revamp the healthcare delivery system will need to forge closer relationships with providers, be engaged more with members to help them manage their health, and create better alignment with the government said three health plan executives Thursday at AHIP Institute 2012 in Salt Lake City.
A packed house sat for the general session, "The Role of Health Plans in Creating a 21st Century Health Care System: A Vision for the Future," which provided insight from longtime health insurance executives Scott Armstrong, president and CEO, Group Health Cooperative, Jay M. Gellert, president and CEO, Health Net Inc., and Samuel R. Nussbaum, MD, EVP, clinical health policy and chief medical officer of WellPoint.
"Unlike the past, we have a very short runway," said Gellert who reflected on 25 years of efforts to contain spiraling healthcare costs. "When we look at the fiscal pressures that are facing government, when you look at the frustration of individuals that don't have access to the system, we don't have another 25-year run."
Fundamental to the change needed are the close relationships health plans will need to forge both with the delivery system and the federal government and to work more closely with these entities than health plans have ever done in the past.
As Armstrong noted: "Simply changing the payment structure to get away form the fee-for-service construct is no guarantee that we will achieve the results we want to achieve."
All three executives can point to specific programs from their own companies that illustrate the need to create programs that fundamentally change the role of private payers that actively manage the health of members as opposed to simply paying for the care they have received.
At WellPoint, one of the shining examples of this kind of integration between insurers is Medicare Advantage company CareMore, which it acquired last year. With CareMore, Wellpoint has built a facility-based model with clinical staff to effectively manage the care of the 15 percent of chronically ill members who account for 75 percent of costs.
By providing a greater level of care coordination and by also actively engaging members in the management of their health, CareMore has reduced hospitalizations by 24 percent, Nussbaum noted.
"We get results," he said.
In terms of working closer with government, Gellert singled out the work his company does through the TRICARE programs which provides healthcare to members of the U.S. military and their families.
The big lessons learned over 20 years, he said, is learning how to segment the population within the TRICARE program to be able to provide specialized care to people with very specialized needs.
"This is a system where we need to fundamentally integrate the private system with a public delivery system in a seamless way," Gellert said. "It only works if military treatment facilities and community facilities are working as one. It is not being done anyway else, but needs to be throughout the system."
Further, TRICARE is the most performance-based system currently operating in the country with more than 460 performance measures collected in real time. The result, Gellert noted, is the health system with the highest satisfaction of any in the country.
"It's not just about saving money," he concluded. "It is about actually about improving care."