How Long-Term Health Plan Enrollment Supports Value-Based Care

Realizing value-based care success is easier said than done. While a primary goal of value-based care is to improve long-term health outcomes and costs, that can be difficult when consumers’ healthcare journeys are disrupted each year.

In simple terms, it takes longer than 12 months to meaningfully change health outcomes, placing the notion of annual enrollment in direct opposition to value-based care.

Moving from annual enrollment to long-term health plan enrollment can help encourage investments in care that will lead to lasting improvements, according to Sachin Jain, MD, president and chief executive officer of SCAN Group and SCAN Health Plan.

“Having a healthcare system that thinks longer-term is the foundation for everything that’s going to make healthcare better. One of our biggest challenges as a healthcare industry is that we think way too short-term,” Jain told HealthPayerIntelligence.

“A foundation of value-based care is the ability to invest in creating improvements in healthcare outcomes. The issue with investing in improvement is that you invest typically when there is an expected return.”

For this reason, current value-based care efforts tend to focus on acute utilization management, such as reducing hospitalizations or readmissions. While payers and patients can certainly benefit from this kind of prevention, it has little impact on long-term health.

“The things you would do if you were trying to improve healthcare costs or outcomes over the long term would be very different from the kinds of things you would do if you were interested in changing costs and outcomes for the short term,” said Jain.

Annual enrollment results in an ever-changing member population for health plans, making it difficult to promote long-term value. Meanwhile, longer-term enrollment stretches can give payers a new path to value.

“In a world in which you had a longer-term time horizon, you might make deeper and bigger investments in true chronic disease management, population health, and prevention, as opposed to just trying to manage transitions of care better or trying to divert patients from the emergency room to a skilled nursing facility,” Jain explained.

Jain is calling for a three-year enrollment period. While a five- or ten-year period would ideally lead to the most optimal health outcomes, a shorter stretch would help mitigate concerns of consumers losing choice.

If health plans can invest in a member’s care over three years, that care would look far different from how it is now, according to Jain.

For example, plans could invest more in social determinants of health initiatives, such as food benefits. Additionally, plans could offer members digital tools and technologies that would not generate a return on investment in a six- to 12-month period but would work over a multi-year timeline.

Jain’s view of long-term enrollment includes exceptions allowing members to switch plans prematurely if they move geographies or have multiple unaddressed grievances with their health plans.

“There’s a lot of people who believe there’s something magical about one year. I want to start to try to fracture that myth,” Jain said. “There’s another group of people who believe the primary thing patients care about is choice, and I want to fracture that myth too. I think the thing that people care most about is competence and excellence.”

Eliminating annual enrollment also has important health equity implications, as minority and low-income populations are disproportionately impacted when the healthcare system operates with a short-term lens. Long-term enrollment could help undo the downstream effects of people having experienced poor social determinants of health, Jain shared.

The first step toward long-term health plan enrollment requires action from the Center for Medicare and Medicaid Innovation (CMMI). CMMI should launch an opt-in test, placing the responsibility on payers to convince their members to commit to their health plan for three years instead of one. In this scenario, plans would have to demonstrate to members how additional investments would benefit their long-term health.

A good starting place for this transition is Medicare Advantage. Since Medicare Advantage beneficiaries are also eligible for Medicare, they won’t be switching between markets, which creates an initial sense of stability.

“The opportunities to move healthcare costs over a three-year period are profound in the older adult population,” Jain noted.

Older adults deserve consistency and optimized care in the time between the start of Medicare eligibility and the end of their life. But the ten years before a person becomes eligible for Medicare are also crucial, as what happens during this time can shape health outcomes in the years following age 65, he added.

While it may seem like a complete upheaval of the current system, shifting from annual enrollment to long-term enrollment offers a clear path to advancing value-based care.

“Healthcare stakeholders and regulators need to wake up and start to acknowledge that the abnormal things we think are normal aren’t normal. Thinking about health outcomes in a one-year life cycle is not normal,” Jain concluded.