Your How-To Guide to Proactive Care and Risk Management | Part 1: Understanding the Obstacles

Everyone understands the why of value-based care: improved outcomes, lower costs, risk reduction, etc.

The real question is how?

How can health plans implement a comprehensive value-based care model that is both practical and cost-effective?

The case for value-based care appears to be gaining momentum post-Covid, with a potential valuation of $1 trillion in enterprise value for payers, providers and investors, according to Mckinsey and Company. But many health plans are still reluctant to lead the way with value-based care until they are confident they have the means to effectively manage and reduce the risks associated with such a model.

In the next five blog posts, we’ll be discussing how an integrated, proactive care model – one that transforms patients from passive recipients of their care to active participants in their health and well-being – drives the risk-reducing member engagement that is a vital component of value-based care.

It’s a complex subject, of course, so let’s take it one step at a time. In today’s blog, we begin by examining the issues within the current healthcare system that must be addressed and the obstacles that must be overcome in order to accelerate the transition from reactive, transactional healthcare to one that is proactive and relational in order to deliver on the promise of value-based care.

Fragmented and Frustrating: The Current Healthcare Member Experience

Today's healthcare system creates a transactional and discontinuous relationship with consumers, which creates significant negative impacts for both patients and health plans alike. Today’s system can best be described as a reactive "sick care" model because it primarily focuses on symptom management and addressing immediate medical needs, rather than taking a holistic view of an individual's health profile. Unfortunately, virtual follow-ups that support patients in adhering to their post-visit treatment plans are few and far between.

This disconnected care model leaves members confused and frustrated, particularly when they are responsible for managing their own care and navigating the care system after a primary care physician visit or hospitalization. As a result, they often disengage from their treatment plans, increasing the likelihood of complications, readmissions, and higher costs for the payer.

Over 25% of hospitalizations each year are related to medication non-adherence.
Inadequate care coordination and poor care transitions contribute to up to $45 billion in unnecessary healthcare spending.
Approximately 30% of new prescriptions, including those for chronic conditions like diabetes and high blood pressure, go unfilled.

Another consequence of the reactive care system is the inappropriate utilization of emergency rooms. When urgent medical needs or complications arise, or when patients are unsure how to manage a condition and determine the appropriate level of care, they often default to the most convenient, costly options, such as the ER or Urgent Care. This leads to a staggering $47 billion in unnecessary costs annually.

Health plans also face the challenge of numerous digital point solutions entering the market, promising to improve outcomes and reduce care costs. However, this proliferation of solutions can create a disjointed and confusing experience for members, who must engage with multiple apps without any attribution to the plan. Care teams associated with these solutions often lack the tools to obtain a holistic view of a member's health history, further contributing to fragmented care. Additionally, there is little evidence to suggest that these point solutions have made a significant impact, partly due to the transactional nature of engagement and the lack of necessary data and interoperability to integrate with other systems and providers.

All of these examples highlight how the current healthcare system is missing major opportunities to impact patient lives, transform health trajectories, and transition from reactive to proactive engagement.

The most opportune time to engage with patients and build a long-term relationship is immediately after a medical visit, hospital discharge, or prescription fulfillment.

At this critical moment, patients are more motivated to take action because they are experiencing the seriousness of a real medical issue firsthand. But during this short time of opportunity, the current siloed system offers little to no support. Instead, members are left to deliver their own follow-up care or decipher their prescriptions. There is no mechanism in place to trigger follow-up support precisely when members are most receptive. And the current healthcare system has trained consumers to be dependent on the system only when they have an acute need and not to engage in their benefits for proactive support.

So, how do we change this?

In our next blog, we’ll discuss how health plans can transform the current fragmented healthcare experience by enabling a comprehensive after-care program of support that coordinates their care journey and guides them to the next best step of risk-reducing engagement (e.g treatment compliance, medication adherence, lifestyle management, etc.).

Endnotes

Jennifer Kim, P. (2018, January 19). Medication adherence: The elephant in the room. U.S. Pharmacist – The Leading Journal in Pharmacy. https://www.uspharmacist.com/article/medication-adherence-the-elephant-in-the-room

Transitions of care. NCQA. (2023, January 23). https://www.ncqa.org/hedis/measures/transitions-of-care/

Brody, J. E. (2017, April 17). The cost of not taking your medicine. The New York Times. https://www.nytimes.com/2017/04/17/well/the-cost-of-not-taking-your-medicine.html

Paavola, A. (n.d.). Unnecessary ER visits cost $47B a year, report finds. Becker’s Hospital Review. https://www.beckershospitalreview.com/finance/unnecessary-er-visits-cost-47b-a-year-report-finds.html

The Pager TeamJuly 5, 2023