Value-Based Reimbursement: Collaboration Required to Lower Costs and Improve Care

Our recent consumer survey showed that 47% of the 3,000 respondents postponed care. And of that 47%, 55% delayed routine visits, 39% elective treatment, 32% essential treatment of a chronic condition and 22% emergency care. This might be slightly elevated because of the fear factor related to COVID-19, but many people may not be aware that consumers postpone care all the time. Many times, it’s because of the desire to avoid high costs.

So, it’s no surprise that when asked what services would improve the consumers’ current level of satisfaction with their health plan, tools or information to help understand benefits and financial responsibility (55%) and to help find less costly care (49%) topped the list.  Confusion continues beyond just transactions and expenses; the consumer survey also found that 50% of insured American adults don’t know all the services covered under their health plan.

Confusion around health insurance costs and coverage leading to delayed care is critical for payers to address because healthcare is changing, and the focus is shifting to quality. As the industry moves to value-based reimbursements, members avoiding care can actually drive costs up. Many regulations are requiring evidence of quality in the hospitals, health plans and clinics, etc. As a result, providers can be rewarded financially for demonstrating quality and keeping patients healthy. The benefit to payors is, if members are kept healthy, costs for everyone can decrease, and member satisfaction can increase.

For a high-risk Medicare member, a health plan might receive several thousand monthly reimbursements from CMS to care for that member. If the member gets sick, the cost of care chips away at that reimbursement. If the health plan and the provider work together and keep that member healthy, everyone benefits, including from a financial perspective.

Preventative care and proactive treatment to keep members healthy benefits everyone in the healthcare ecosystem. However, there’s a communication gap when it comes to supporting and promoting preventive care.

According to the consumer survey, when asked if a health insurance company, primary care physician, or a specialist directed the consumer to a community resource like Meals on Wheels or housing assistance to further support their care, 72% said no, including 83% of Medicare Advantage members and 77% of Medicare members.

“There is a significant communication gap and missed opportunity for the most vulnerable populations to take advantage of the resources available to help improve their care and overall well-being. There is also evidence that consumers will use these resources if they know they exist. For those directed to community resources, 81% engaged with the services—up from 57% in 2019.”

Consumers want tools to understand their costs, benefits covered, community resources, and overall better communication; if payers and providers work together to improve outreach and overall transparency, it will keep members healthy, lower costs, and benefit everyone in the long run.

About the Author

Len Rosignoli

Len Rosignoli, Vice President, Customer Success

Len Rosignoli is a healthcare technology and operations executive with extensive managed care insurance expertise spanning more than twenty-five years. He joined HealthEdge in early 2020 as an Account Executive, supporting the strategic needs of a portfolio of HealthEdge customers. Prior to joining HealthEdge, Len spent the prior six-and-a-half years as the Chief Information Officer for CalOptima, a Medi-Cal plan, and one of the top 12 largest Medicaid MCOs in the country. Len also held executive IT roles for a variety of health plans supporting all lines of business in a range of geographic areas on many technology platforms. His experience includes mergers & acquisitions, large-scale core system migrations and implementations, and support of the full scope of the technology, including application development/support, project management, infrastructure, and cybersecurity.
GuidingCare Connects the Entire Care Community to Achieve Better Health Outcomes

GuidingCare’s streamlined and automated workflows help health plans save time and money. Download the infographic to learn more about the benefits of GuidingCare and the tangible results health plans have achieved using the platform.

Health plans ecosystem

Subscribe to The 'Edge Report Blog