Industry Voices—Employer-sponsored health plans: Where do we go from here?

Documents summarizing an employee's health benefits
The COVID-19 pandemic has ushered in a new era of active healthcare consumerism that could have positive, lasting impacts on cost and quality. But, only if insurance design can appreciate and support consumer motivation. (zimmytws/Shutterstock)

The stakes have never been higher. Employers are financially strained, looking for ways to cut costs and fighting like crazy to keep their employees on the payroll. At the same time, good healthcare benefits have never been more important to people.

It’s time we do something different and break the healthcare cost curve for employers. Employers want to offer quality benefits without breaking the bank or doing it on the backs of employees.

Consumers are ready, too. We’re now more motivated than ever to make sure we’re making the best care decisions possible. The fear of exposure to COVID-19 has triggered us all to use the healthcare system more thoughtfully, and in many cases, more efficiently. The pandemic has ushered in a new era of active healthcare consumerism that could have positive, lasting impacts on cost and quality. But, only if insurance design can appreciate and support consumer motivation.

Better insurance design is an immediate way to get there. It’s time we move away from insurance design centered around doctors, hospitals and drugs and move to a condition-based health plan design that creates an intuitive fit between people’s health insurance and the way they actually use healthcare. We have to create an infrastructure and experience through which people can find more effective (higher quality) and efficient (lower cost) methods to solve their health conditions. If we can do this, everyone benefits.

RELATED: COVID-19 outbreak could drive up employers’ healthcare costs by 7%: analysis 

There are four tenets required for health insurance design that truly supports active consumerism.

Personalized insurance. My health needs are not the same as your health needs. That’s always been true. Yet, traditional health insurance plans herd consumers down set paths. We’re given a list of in-network providers. We pay the price an insurance company has negotiated—but won’t know the cost until the bill arrives. And we go down the treatment path our doctor recommends, often without knowing all our treatment options and without being able to compare costs. We rarely have the information we need to feel confident we’re making the right decision—for ourselves, personally.

It doesn’t have to be this way. The data and technology needed to deliver a personalized and flexible experience exists today. We have to give people the tools to make informed choices, before they make care decisions, that are right for their unique circumstances, when they need it.

Insurance should also learn about a person, build context about them, their motivations and what they need—and be responsive to that need. With artificial intelligence and machine learning, this is already possible.

Condition-based coverage. People don’t search for hospitals, doctors and drugs. They want to solve their condition. If I have knee pain, all I care about is the best way to get rid of it. A health plan that supports active consumerism will answer that question by illuminating the entire path of treatment options with clear prices. With COVID-19, the entire industry has rallied together with a condition-based approach. We need to do that for every single condition, because that’s how consumers shop.

Affordability. Deductibles were introduced into employer-sponsored health insurance to give employees more “skin in the game.” The theory was that people would become smarter shoppers and more motivated to control costs if they had to pay 100% of their treatment costs out of the gate. But it’s pretty hard to shop when you can’t find prices. And it’s pretty hard to purchase when you can’t afford to fund 100% of your care until the deductible kicks in.

RELATED: Study: U.S. employers' medical costs set to rise 6.5% in 2020

People deserve to know the cost of care upfront and should have the ability to price shop and save money. When people are aware of the cost of care in advance, they can make educated decisions that work for their unique circumstances.

When people don’t have cost certainty and/or are faced with high deductibles, many of them skip or postpone care. That is not a health benefit. A deductible for cancer, chronic conditions, infectious disease, etc., is a terrible idea. It’s time to remove unnecessary affordability barriers like deductibles and co-insurance.

Incentives for effective, efficient choices. People need reliable, real-time information to support better decision-making. There should be clear economic signals (price tags) that guide people toward more effective and efficient options. Today, consumers are unable to see that there are effective treatment paths and ineffective treatment paths for every condition. Harnessing clinical evidence, we have to bring that to light and put the financial incentives in place to support behavior change.

Under this concept, consumers should pay less for providers and treatments that are more likely to get them or keep them well. One example of an often effective, efficient choice is telemedicine, which is finally seeing its day and becoming more accessible. Doctors and patients alike are now realizing the benefits of virtual care. It’s convenient, scalable and costs less. Health plan design needs to incentivize telemedicine in a more significant way, moving forward.

A clear path forward

Now is the time to build something new. It’s time to build the platform that helps consumers find the care they need, delivering choice and value every step of the way. We shift our mindset and lexicon from patients to active participants. From treating illness to maintaining health. And employers can positively affect employee health in ways that will likely have them spending better.

A line has been drawn in the sand, and we can’t go back. The time to stand up and do something different is now.

Tony Miller is the CEO of Bind