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Patient Engagement Helps Payers on Affordable Care Act Exchanges

Patient engagement may help private payers offset the financial losses seen on the Affordable Care Act exchanges.

By Vera Gruessner

Many health insurance companies selling health plans through the Affordable Care Act exchanges have been seeing higher and higher rates of financial losses. Some payers such as Aetna, Humana, and UnitedHealth Group have even pulled back from selling plans through the public marketplace. UnitedHealth, for instance, saw a loss of $475 million in 2015.

Patient Engagement in Healthcare

Some of the challenges that payers face on the Affordable Care Act exchanges include general instability when it comes to revenue streams as well as a higher risk pool that leads to costlier medical claims. For example, Humana predicted at the beginning of this year that it would lose $176 million in 2016.

Payers that have committed to serving customers through the Affordable Care Act exchanges may need to improve their patient engagement strategies in order to advance preventive and primary care, which are expected to help reduce healthcare spending.

The way that patient engagement could reduce healthcare spending stems around keeping patients healthy outside of the doctor’s office. Patient portals and secure text messaging capabilities are able to strengthen patient-physician communication, which allows doctors to keep track of patients’ progress and medication adherence outside of the clinical setting.

Proteus Duxbury, Healthcare Insurance Industry Expert for PA Consulting, told last month the importance of patient engagement and satisfaction when it comes to boosting revenue through the Affordable Care Act exchanges.

READ MORE: Why Payers Should Include Consumer Engagement in Health Plans

“Payers have been talking about engaging the consumer for many years, but few have realized a significant return on their investments to date or been able to really generate lasting value through the execution of their strategies,” Duxbury said. “Increasing medical loss, however, and low healthcare literacy of consumers within the exchange market is creating renewed impetus to succeed in helping the consumer enroll in the right plan and utilize it in a cost effective fashion.”

Private payers may also look to the Centers for Medicare & Medicaid Services (CMS) when attempting to improve patient engagement. Patrick Conway, M.D., Principal Deputy Administrator and Chief Medical Officer at CMS, announced in The CMS Blog the creation of two new models to strengthen patient engagement among Medicare providers and bring the patient voice into clinical decision-making.

The two models are called the Shared Decision Making Model and the Direct Decision Support Model. The Shared Decision Making Model will encourage providers operating through accountable care organizations to share treatment information and clinical data with beneficiaries so that patients understand the risks and benefits of certain regimens as well as potential alternatives.

Under the Shared Decision Making Model, physicians would be able to incorporate the patient voice into clinical decision-making and customize a treatment based on the best medical evidence along with the beneficiary’s preference. CMS will be testing whether this model leads to better patient satisfaction, lower spending, and improved quality of care.

The Direct Decision Support Model is based on incorporating decision support tools outside of the physician practice. Decision Support Organizations would be able to send beneficiaries websites and applications with relevant information on their treatment and condition. CMS will be testing this model to see whether engaging patients outside of the clinical setting will help improve patient knowledge and overall wellness.

READ MORE: The Progress and Challenges of the Affordable Care Act

“An independent evaluation will be conducted separately for the SDM and DDS models. The goal of the evaluation is to determine whether the particular model improves the quality of care without increasing spending; reduces spending without reducing quality of care; or improves quality of care and reduces spending,” The CMS Blog stated.

“These models will look to move beyond current practices and examine new ways to engage with patients with regard to their health and health care, and hopefully increase quality of care delivered, increase patient satisfaction, and provide value in the cost of care delivered. Both of these models incorporate lessons learned in previous CMS projects that included patient engagement and shared decision making components.”

Private payers could follow the lead of CMS and boost patient engagement through clinical decision support tools and applications. Insurers could also incentivize physicians in their provider network to discuss treatment options with their patients before proceeding with any regimen.

Another solution that payers could use to boost patient engagement is to survey their patient base about their needs, concerns, and potential fears regarding treatment options. Providers could use survey information to create a more patient-centric healthcare setting.

Facing higher risk pools on the Affordable Care Act exchanges than expected and continual financial losses, private payers will need to work to improve patient engagement by investing in clinical decision support tools and incorporating member surveys.  

READ MORE: Private Payers Face Challenges on Health Insurance Exchanges


Dig Deeper:

The Progress and Challenges of the Affordable Care Act

How Payers Could Succeed in ACA Health Insurance Exchanges


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