We have sought multiple approaches to help Employer Clients and Benefits Consultants understand the value of Primary Health services paid for under a value-based arrangement versus traditional fee for service alternatives in the community. This same “comparison framework” problem exists within the Medicare Advantage (MA) space when trying to select between different plan types, benefits, and options. Sachin Jain, MD, the CEO of SCAN Health Plan, shared his opinion in a recent Forbes article about how he would fix both the comparison and subsequent competition problems within that industry and I have shamelessly modified his post to reflect the same argument for the commercial sector as we introduce Primary Health to employers, employees, and their families.
After years of free-wheeling budgets and scant analysis, employers are finally beginning to dig into ensuring they are getting real value from their health care spending. We have seen this via a general pullback in new point solution investments as well as the movement to redefine health care value as “patient-relevant outcomes achieved divided by the cost per member to achieve the outcomes,” This reframing is critical for employers in order for them to justify the added cost of employer health benefit programs delivered by innovative primary care companies providing a full range of health services for employees and their dependents.
There are many reasons that employer sponsored “Primary Health” will cost more than traditional fee for service primary care in the community. Most notably, Primary Health offers a much richer array of services to employees and their dependents—not just primary care but also mental health, physical medicine, health coaching, fitness, and the option to include care navigation—and delivers this in a comprehensive, integrated, and coordinated fashion purpose-built to fit into the employer health benefits ecosystem. Furthermore, employers who partner with national medical groups like Crossover can get a single, accountable partner to deliver health services in all 50 states in person, online, and anytime.
That said, I think employers and the consultants who advise them should look beyond the simple but slothful “cost per visit” analysis which is an impossible “apples to oranges” comparison for two very different payment and care delivery models. The challenge for medical groups like Crossover shouldn’t be to find parity with community-based fee-for-service or defend our care model’s relative merits or even cost effectiveness. Rather, our challenge should be to show how much “better” care and outcomes can be in true value-based models and tie those performance metrics to the correct measurement of value as defined above.
To achieve this–and for Primary Health to finally live up to its enormous potential–employers and consultants should step away from skirmishes around “cost per visit” and cherry picking specific program line item costs without looking at budgets more holistically. Instead they should focus on much more fundamental total cost of care analysis along with specific quality, experience, and engagement metrics that matter most to employers who sponsor these programs and the employee members who benefit from these services. In order to do that, I am proposing a set of standardized metrics we believe best measure cost, quality, and experience for employer health services. But first, let’s see what we can learn from the Medicare Advantage experience in how they have overcome similar comparisons and how they differentiate value from traditional care delivery.
Learning from Medicare Advantage (MA)
When people compare MA plans, they obviously look at plan costs but often make their selection based on the benefits offered. A Commonwealth Fund survey shows that about 25% of people choose MA plans for the added benefits. Some of these benefits are outstanding: low co-pays and zero-cost medications. Others, like dental and vision coverage, are noteworthy. And yet others—like cash cards—might attract members’ attention even if they don’t provide them with much in the way of healthcare when they need it. Unfortunately, this created marketplace confusion surrounding the multiple types of coverage, benefits, and understanding the value (outcome / cost) of the different products.
This, in turn, led Representative Ron Wyden and other Congressional colleagues to force payors offering these plans to consolidate their products to fit a handful of clearly-defined benefit types, thereby compelling insurers to compete on the price and effectiveness of these plans, instead of benefits that were designed with marketing in mind. The new system worked, and thanks to continued tweaking from policymakers, it still works today. Further enhancements have come in the form of Center for Medicare Services Five Star Ratings that allow an additional comparison of plans on metrics like care quality, provider responsiveness, and customer service that became important measures to compare plans.
Measurements That Matter for Employers
While a scoring system exists for selecting between MA plans, there is nothing similar for employers when evaluating the value they get for their health benefits spending. This is true not only for care delivery but more importantly for digital health solutions. While traditional HEDIS and HCAHPS are helpful metrics across a broad spectrum of health outcomes, they have not been uniformly captured, consistently available, or adequately applied when comparing different commercial primary care offerings. Put another way, employers should be part of consensus efforts to create Star Rating equivalent metrics that are indexed for not just basic health metrics but for those outcomes that matter most to both the employers and the member.
Every medical group (national or community) should be able to tell prospective customers how well their members have fared after common events in their health journey such as health prevention and social determinants screenings, access times to engage with a provider, outcomes of common conditions, health experience of members, and costs per member treated over the course of a benefit year. This last point is essential to capture, as the higher direct costs of integrated Primary Health models look far more attractive when compared to the overall costs of an employee who utilizes care primarily in the community. This holds true for not just primary care but all the other services an employee may access over that year that should be accounted for in the total cost of care.
Employers may also have specific metrics like productivity, absenteeism, retention, or other metrics that matter to them. Likewise, members’ experience should not only be measured by net promoter and satisfaction scores but also by validated questions like “I discussed the issues that were most important to me”, “I feel understood and respected by my clinician”, and “I understand and agree with my treatment plan”. These are much better measures as well as indicators of health care affinity and member-provider “fit”All of this can be translated into a simple scorecard that could be presented to employers about how well each group is performing.
While not all ratings will have the same meaning or applicability across all situations, we can definitely start by attempting to standardize measurements. I applaud early efforts by Massachusetts and others to get to a standardized primary care scoring system. This will allow both obvious and subtle differences between care delivery providers and care delivery approaches to be highlighted. It will also allow standards and benchmarks to be readily available so that each care provider can be appropriately recognized for the unique work they are doing (or not doing!). The key point here is that standardized metrics will allow different care delivery models and different medical groups to objectively highlight their differences and for purchasers to have a much clearer–and more objective–way to evaluate the outcomes and true level of cost on standardized metrics across the Triple Aim of Cost, Quality, and Experience.
Primary Health lends itself to the creation of Commercial Advantage
I have spent much of my career leading teams who are dedicated to fulfilling Primary Health’s great promise as the foundation of an effective, efficient, and engaging health system that creates real value. When a care delivery team is incentivized to keep patients healthy, and when there is no incentive to make more money by simply performing more medical services, employer payers and Crossover care teams are not only better aligned but are paid in a manner that enables us to help each member better achieve their health goals. That has always been and continues to be the entire point of Primary Health and the complementary “Commercial Advantage” benefit designs that we are just starting to introduce into the marketplace.
Our mission, as a leading national Medical Group focused in the Employer Health industry, is to align every possible incentive in the direction referenced above. Instead of attracting new clients with lower “cost per visit” criteria that glitter like fool’s gold, we will standardize on Metrics that Matter and drive real health care value. These objective measures would create a more accurate competitive framework to differentiate between care delivery models. In the end, while value will always remain subjective, a clear definition of value (the outcomes divided by the cost expended to achieve them) and standardized, comparable metrics will create a defensible justification to make the investment in legit Primary Health.