- Chronic disease continues to lead to heavy healthcare spending and health payers have aimed their sights on better understanding methods for preventing and addressing chronic medical conditions. Both private and public payers such as the Medicaid program have established beneficiary incentives so that more consumers focus on maintaining a healthy lifestyle.
A greater emphasis on health and wellness along with patient engagement may go a long way toward reducing the risk of certain chronic medical conditions and, thereby, lower healthcare spending. Some beneficiary incentives from state Medicaid programs for those who’ve taken part in healthy behaviors such as doctor-recommended diets and fitness routines include “gift cards, cash, gym membership coverage, meals, childcare, and transportation.”
Along with beneficiary incentives, it is important to include the patient voice in discussing methods payers can take when battling chronic disease and educating customers on health plan options, explained Michael Kaplan, President and CEO of AIDS United. When the patient is satisfied and engaged, it could lead to better outcomes and essentially decreased healthcare spending.
“I would say that the most important part is engaging in a dialogue,” Kaplan told HealthPayerIntelligence.com. “I remember not too long ago, there was a new head of Pharma and payers were creating a dialogue.”
“The one thing missing was the patient voice,” he continued. “While health payers are engaging with Pharma, there needs to be a 3-way dialogue. It should not be just the providers and payment process reps like private insurers but the 3rd voice needs to be the patient and consumers who tend get the short end of the stick.”
For more information about solutions health payers can take to address chronic medical conditions like multiple sclerosis and reduce healthcare spending, HealthPayerIntelligence.com spoke with Bari Talente, Executive Vice President of Advocacy at the National MS Society.
HealthPayerIntelligence.com: Why did the National MS Society choose to join the Partners for Better Care organization?
Bari Talente: “About two years ago, the National MS Society formed a taskforce to develop principles around access to high-quality MS healthcare. We had people from across the country including people with MS, family members, health policy experts, healthcare providers, and Society staff. We spent about 10 months talking with experts, sharing information, and discussing the experiences of people with MS in accessing the care that they need to live their best lives.”
“By the end of that work, we developed the Society’s access to high-quality MS healthcare principles. It’s a number of principles around what we think quality healthcare should look like for people with MS. We have six principles that cover a broad range of things, but the first one is that people with MS are at the center of their healthcare decision-making.”
“That’s really the reason why we joined with Partners for Better Care. We really see a growing need for the patient voice to become more prominent in how healthcare decisions and treatment choices are being made. We believe that the choices for people with MS about what medications to take or other relevant treatment options should be between the person with MS and their healthcare provider.”
“That should be a partnership that the person with MS and the healthcare provider have in talking through options, assessing the risk and benefit tolerance, and where they are in their life and disease course so that they can make the best choice for the individual person.”
“What we’ve seen over time is that choices are driven more and more by external factors. It can be driven by the cost of the MS disease modifying therapies or it could be driven by the formulary options that an insurer has. The choices are being taken out of the hands of people with MS and their healthcare providers and we want to make sure that people with MS are really at the center of their options.”
HealthPayerIntelligence.com: What type of health coverage issues have you noticed affect people living with MS?
Bari Talente: “For people with MS, they are most affected by formulary decisions because the expert advice is that people with MS should be on MS disease modifying therapy early and stay on that therapy as long as the person with MS and the healthcare provider think is necessary and that therapy is working for them.”
“That’s one of the primary issues that we see – the formulary decisions. That includes the medications that are actually included on a formulary as well as where a medication may appear on a tier and prior authorization along with step therapy.”
“We’ve also seen people with MS be affected by some of the narrow networks and the choices of healthcare providers.”
“I would say that one of the trends we’re seeing that is really problematic for people with MS is that we’re seeing some formularies change from year to year. As the formularies change, the insurers and pharmaceutical benefit managers are attempting to move people with MS from one therapy to another. That is not in line with the best medical opinion and advice for MS. Once a person is stable on a medication, they should remain on that medication unless there’s a medical indication that switching is necessary.”
HealthPayerIntelligence.com: How can health payers move toward solving the many coverage issues plaguing patients with MS as well as improve health literacy and transparency?
Bari Talente: “I think health payers could improve the benefit for people with MS as well as outcomes for people with MS if their decision-making was more patient-centered. If that patient voice was included in helping to decide which medications to cover and with what level of ease people should be able to move through medication options.”
“Healthcare payers are very interested in adherence to medication and the best way to get there is to listen to what patients need and want from their medication. That may differ from person to person not only based on the medication, but based on the mechanism of action and based on the route of administration.”
“For some people, they’re not able to manage a self-injection with their lifestyle. It may be due to a phobia about self-injecting or due to traveling a lot for their appointments and self-injection medications are not a viable option for them with that level of travel.”
“Factoring those things into decisions about what medication a person should be on will improve adherence and help insurers make sure that the decisions they’re making are right for people with MS.”
HealthPayerIntelligence.com: Do you think that the movement toward value-based care payments will make a real impact on improving the quality of care for MS patients?
Bari Talente: “The value conversation is a very important one to have. How it’s had and what’s included in determining what value means is incredibly important for a disease like MS where it’s a lifelong chronic condition.”
“If you look at value and outcomes over only a very short period of time – 18 months to two years – while you can point to what that value looks like in something like a cancer treatment, you cannot point to what that value looks like in a disease like MS. It’s much like longer term.”
“The value conversation is very important to have but we have to make sure that we’re incorporating the right factors for each type of medication and disease.”