Why Payers Need to Address Patient-Centered Medicine

May 19, 2016 - The healthcare insurance industry needs to meet the demands of consumers looking for quality provider data. Patient-centered medicine is becoming a mainstay throughout the country and cost transparency is a major aspect of this movement. Along with price transparency, patient centered medicine requires health payers to create a strong provider network consisting of physicians capable of addressing patient needs and offering services covered under the health plan.

According to a company press release, IDC Health Insights released a new report called IDC PlanScape: Directory Accuracy and Network Adequacy — For Payers, the Time Has Come, which details Solutions that health payers can follow to improve the accuracy and quality of provider data as well as form a stronger provider network.

Health payers will need to continually meet customer expectation within the model of patient-centered medicine as well as ensure provider accountability and data cleansing. Health plans can achieve provider network adequacy by creating a network of a sufficient number of specialists and primary care physicians who offer the benefits available in a particular health plan.

There are specific reasons why provider network adequacy and the accuracy of the directory are becoming key areas health insurers need to focus on. For instance, health insurance companies must comply with the Affordable Care Act and other regulations to show network adequacy.

Also, consumer demand is becoming more common because of the health insurance exchange’s online presence and faster ability to search for providers. Essentially, the report from IDC Health Insights found that health payers will need to bring more focus to the accuracy of their directory and the adequacy of their provider network in order to succeed in the changing healthcare landscape.

“Customer engagement with payers starts day one when the patient checks to determine if their set of doctors is local, in-network, available for new patients, speaks their language, and is convenient. If that consumer information is later found to be inaccurate or inadequate, a payer's brand is tarnished forever, and with the increase of the individual marketplace, consumers will go elsewhere,” Jeff Rivkin, research director for Healthcare Payer IT Strategies at IDC Health Insights, stated in the press release.

“High-visibility rulings have penalized over a quarter million dollars in fines to two commercial payers for ‘misleading’ consumers about their networks; and one judgment resulted in $15 million in rebates to customers. CMS has imposed significant fines for inaccuracies, and the newly-engaged state legislatures threaten new mandates and fines. Most importantly, the new consumer engagement paradigm is driving payers to finally pay attention to the directory and network ecosystem.”

With some major health insurance companies facing challenges in maintaining profit when selling plans on the health insurance exchange, it grows imperative to meet these consumer demands and maintain the right approach to patient-centered medicine.

With UnitedHealthcare leaving the exchanges in 2017, it is probable that other health payers may follow suit if they experience financial loss. As such, consumer engagement may be a necessity for maintaining success when operating through the health insurance exchange. In the midst of changing healthcare payment structures, payers will also need to watch out for providers forming their own health plans and networks.

One organization, Memorial Hermann Health Solutions, has even formed its own platform through which to sell health plans much like that of the insurance exchanges. At this point in time, the establishment has been able to enroll more than 8,000 members by incorporating consumer engagement strategies.

“We tried to do a lot of things to change the way we approached consumer engagement for 2016. Historically, our health plan had been geared towards brokers as well as employers. Then the changes that accompanied the Affordable Care Act really put an emphasis more on the individuals and targeting consumers," Neil Kennish, Associate Vice President of Marketing and Sales at Memorial Hermann Health Solutions, told HealthPayerIntelligence.com.

“We made a lot of changes to really make sure that we were communicating and approaching individuals on a direct level. Our marketing materials allowed the individual consumer to get a better sense of what is health insurance.”

“We tried to take an approach where we either did focus groups or did surveys of our existing customers to get a better sense of what critical benefits that they need to make sure are covered without them having to be concerned. What are benefits that need to be explained in detail so that people understand the difference between copays and coinsurance rates? We try to take away some of the questions and uncertainty around health insurance so that it is an easier decision for them.”

Even though there are a wide range of payment reforms taking place between payers and providers as well as regulatory changes affecting the healthcare landscape, consumers purchasing plans on the exchange report satisfaction with their insurance policies, according to a study from Deloitte Consulting LLP.

“Out-of-pocket costs have been increasingly top-of-mind for health care consumers as the nature of insurance has changed over the past several years,” Paul Lambdin, director, Deloitte Consulting LLP, and exchange practice leader for the plans sector, said in a public statement. “This cost issue appears to be making exchange consumers pay close attention to the details of their coverage, and changes in benefits and premiums year over year.”

Fewer consumers are concerned with future medical bills and more are able to access medical care today due to greater coverage. More consumers using the exchanges are now shopping for plans by comparing and contrasting policies, which is in contrast to those obtaining employer-sponsored healthcare coverage.

“We’re witnessing the continuing evolution of a more consumer-centric model of health care, and the ways in which consumers are navigating the exchanges provide evidence of that,” explained Greg Scott, Principal of Deloitte Consulting LLP.

It would benefit health insurance companies operating through the exchanges to offer affordable and flexible health plans that address patient satisfaction. Health payers will need to meet consumer demands  in order to succeed with the rapidly changing healthcare reimbursement structures, which means consumer engagement, provider network adequacy, and directory  data accuracy will need to be superior.

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