In my last post on cost transparency, I mentioned how the provider is paramount over the payer in the eyes of the patient/member. Some payers have made this the focus of their strategic growth plans and are methodically moving to become part of a payer-provider “payvider” model. This vertical integration is on the rise for payers, most notably for: UnitedHealth Group, CVSHealth, Cigna, Elevance and Humana.
There are some serious up-sides to this model from a bottom-line perspective:
- When payers and providers merge, they do so because they predict increased profitability.
- This merge diversifies revenue.
- The diversification spreads financial risk.
What’s in it for the patients/members?
The hope of value-based care. This means patients and members benefit from higher quality, better outcomes and increased satisfaction at lower costs. This is not to be inferred through a payvider relationship; however, it’s the lofty goal of many payviders like CVSHealth through their “Health Hubs”. As we’ve all experienced, the current fee-for-service model incentivizes the provider into high-volume, low risk patient engagements. This means high # of office visits/day and increased # of tests because there’s no time to fully assess the health situation of the patient. In a payvider model, the spread of financial risk provides more breathing room for providers to focus on value-based care.
- In sum, patients/members have more meaningful provider engagements = less unnecessary spend in healthcare = increased payer profit (through overall reduction in cost of care) = payvider system spread its risk
The model works
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Research has proven that the payvider model is successful with patients but it requires thinking about healthcare consumers in a new light. “Vertically integrated models of patient care and coverage have been shown to outperform other models of care and coverage in patient experience and perception1.”
A shift in advocacy – What I like about this model is that the provider is doing what the patient has always wanted them to do, advocate on their behalf. When you spend the time on prevention and wellness, you can reduce healthcare risk and spend. This result is the ‘wellness company’ that many payers have been striving to become for years.
How should integrated models of healthcare engage their patient/members differently?
Should we call them pat-bers? Mem-tients? It doesn’t nearly have the same ring to it as Payvider and Bennifer.
They want the ultimate in connected, personalized care. The digital experiences should complement the health advocacy from their providers.
- Give me one “umbrella” digital experience across all of my healthcare experiences – this means one authenticated environment with many connected channels
- Suggest the best providers for someone like me, given preferences, desired outcomes and total cost (including my health plan coverage)
- Suggest the right facilities for each care type – tell me when it’s beneficial for me to wait for my PCP versus head to urgent care versus seeking local speciality care or needing to seek care at an academic medical center
- Help me manage all of my appointments and integrate them into my phone’s calendar and app
- Suggest the drugs that you’ve seen successful for someone like me; and include me in the care decisions around drugs needed to address my medical issue before a drug is prescribed
- Tell me exactly how much I’ll spend before I seek care as of a specific date – for both preventive and complex care needs
- With enhanced focus on wellness, connect my wearable and other devices or apps so that I can integrate data so my providers have a more complete picture of my health. Consider gamification as I seek to earn rewards in my health savings account (e.g. heart rate monitor, sleep apnea machine, fitness and nutrition tracker, etc.)
- Make it easier for me to get to the functions within the authenticated app and portals. Help me give you all the right permissions to help make it happen
- Serve personalized content to me that learns and adapts to what I engage with
- Regarding health advocacy, make it easy for me to share my health data and actions with a person I trust