5 pillars that underpin payer population health strategies

Pillar 1: Break down access to care barriers

Access to care is crucial for population health efforts to succeed. Without the ability to reach a provider, members are unable to improve their health and wellness.

Often, access to care blockages apply regionally. For example, populations in rural areas struggle to establish and maintain proximate provider offices and hospitals. With healthcare options few and far between, rural populations are forced to travel long distances to reach care which may dissuade them from seeking care when needed, could lead to care delays for time-sensitive conditions and may result in an overdependence on emergency departments.

However, challenges related to reaching a healthcare provider are not restricted to geography and distance. The digital divide is just as guilty of perpetuating access to care gaps, with tech-savvy members who have access to digital tools and strong Wi-Fi receiving care more easily than those without these advantages.

One area in which these challenges have a particularly strong impact on population health is the mental and behavioral healthcare space, Antonucci noted. The demand for these services is strong as the mental health crisis continues to worsen: Over half of psychologist participants in an American Psychological Association survey agreed or strongly agreed that the severity of patients' conditions increased (52%). Some respondents said that their waitlists grew longer between the third quarter of 2022 and the third quarter of 2023 as more patients sought care (38%).

Lack of appropriate coverage can present significant barriers to accessing care for members who need mental and behavioral healthcare support. More than six in 10 individuals without health insurance who have moderate to severe anxiety or depression (62%) decided to forego mental healthcare treatment, compared to 37% of employer-sponsored health plan members.

Even insured individuals face access to care issues in this area. Employers hold payers responsible for gaps in access to mental healthcare, according to a National Alliance of Healthcare Purchaser Coalitions survey. While most business leaders recognize the population health impact of untreated behavioral health needs and want to offer appropriate coverage (99%), over three in 10 employers were dissatisfied with their payers' access to care solutions and 26% expressed some level of dissatisfaction with their health plans' in-network behavioral directories. Consumers also hold payers responsible for underwhelming mental healthcare coverage.

However, this is also a space where payers and providers have made incredible headway in recent years, Antonucci pointed out. At Providence Health Plan, for instance, telehealth solutions have been crucial to maneuvering around access to care barriers in mental and behavioral health.

"Because of not only the pandemic but also the advent of more people using telehealth, we've been able to focus on specialized programs that open up that access in a meaningful way for people so that they can at least be seen, helped much sooner and faster," Antonucci said.

Blending Value-Based Care and Population Health Strategies

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In an effort to improve access to care in mental and behavioral health, most payers offer telebehavioral healthcare services, according to an AHIP survey. They expanded their in-network behavioral healthcare provider options. Additionally, 78% of payer respondents increased their behavioral healthcare providers' reimbursement rates. Payers also sought to improve behavioral healthcare capabilities among their primary care providers by offering behavioral healthcare training and a direct phone line to behavioral healthcare specialists.

Pillar 2: Keep affordability as a high priority

For payers, affordability should be top of mind and must be tied into their population health strategies.

Healthcare prices have been increasing and that trend is expected to continue, according to a Peterson-KFF Health System Tracker brief. From 2027 to 2032, healthcare prices are expected to grow at an average rate of 5%, routinely surpassing the GDP.

The rate of increase is unsustainable for payers, providers, employers and, most importantly, for members. Unaffordable care manifests in medical debt, medication non-adherence and delayed treatment. Over half of employer-sponsored health plan members who delayed care for cost-related reasons reported that theirs or a family member's health suffered as a result, according to a Commonwealth Fund survey. The percentage was higher for marketplace, individual-market, Medicaid and Medicare enrollees.

Certain populations have higher rates of spending and, as a result, may encounter more affordability challenges. People over the age of 55 contribute significantly to overall healthcare spending in the U.S., according to an article from Peterson-KFF Health System Tracker. Members who have higher rates of healthcare needs often see higher spending, as do individuals with chronic diseases. And women have more healthcare costs than men between their twenties and early forties.

Value-based care adoption is a crucial facet of the payer response to affordability issues that hinder population health improvements. According to a report from the Health Care Transformation Task Force (HCTTF), payers can alleviate both direct and indirect costs for members through a variety of value-based efforts, including the following:

• Episode-based cost-sharing.
• Price transparency.
• Care coordination.
• Supplemental benefits.
• Food and housing interventions.

Two population-based approaches that the report highlighted were patient cost-sharing waivers and employing community health workers. The Center for Medicare and Medicaid Innovation introduced patient cost-sharing waivers to increase flexibility on copays and coinsurance for specific services, according to HCTTF.

"Waivers are most effective if they can be targeted to specific populations based on clinical conditions, identified social needs, or insurance status," the report elucidated.

Similarly, CMS allows Medicaid programs to explore innovative, population-based cost reduction solutions through 1115 demonstration waivers, HCTTF experts added. While these waivers do not have to tackle affordability, as of Nov. 14, 2024, 43 states have been approved for select benefit expansions (which include eliminating copays for certain populations) and 21 states have been approved for social determinants of health provisions which sometimes include experimenting with alternative payment models.

Additionally, HCTTF noted that providers in value-based care models can use community health workers to target certain populations. These types of efforts are particularly important for members who are in underserved regions. Community health workers can gain access to members in a way that few providers can. As a result, they can identify gaps in care and other challenges that could lead to more complex and costly healthcare needs if left unattended and prevent higher spending.

Pillar 3: Build on established quality of care standards

In all areas of healthcare, access to higher-quality care is tied to better overall outcomes, and this is particularly evident in population health. It is also another area where value-based care and population health goals intersect.

Certain industry standards and stakeholders, such as Medicare Advantage or the National Committee for Quality Assurance (NCQA), can provide a roadmap on quality of care and quality measures for payers to follow, Antonucci advised.

Medicare Advantage and Part D Star Ratings measure health plans on five categories of care quality: member experience with the health plan, customer service performance, member complaints about the health plan, chronic condition management and beneficiary health while enrolled in the health plan.

Because these quality measures are tied to reimbursement in a value-based care system, Medicare Advantage plans are incentivized to score well. Because they are incentivized to do well on these measures, they often go the extra mile and, in doing so, pioneer improvements in the quality of care for members that health plans in other sectors can emulate.

Coming up with those standards of quality that need to be delivered in healthcare and being able to measure that year over year is extremely important.

Over the past decade, Medicare Advantage Star Ratings improved across 90%of the system's quality measures that have been continuously tracked, according to a McKinsey & Company brief. Medicare Advantage plans succeeded at capturing more colorectal cancer screenings, bettering osteoporosis management for women who experienced a fracture and other preventive care measures that can catch conditions before they become serious.

Metrics like the Medicare Advantage Star Ratings can set a quality of care standard for not just the Medicare Advantage sector, but the entire health insurance industry. That being said, experts have pointed out that the difference in quality of care between Medicare Advantage and original Medicare is fairly equal. There is still room for growth on the Medicare Advantage quality of care metrics.

NCQA's Healthcare Effectiveness Data and Information Set (HEDIS) measures also represent a useful benchmark for quality of care. Again, comparing Medicare Advantage plans to original Medicare regarding HEDIS performance can be a good indicator of the value these measures offer. For example, Medicare Advantage plans outperformed original Medicare to a statistically significant degree on 12 out of 14 HEDIS measures, according to an AHIP report.

"Coming up with those standards of quality that need to be delivered in healthcare and being able to measure that year over year is extremely important," Antonucci emphasized.

When quality measures are designed to target high-value care and effectively lead to improvements in quality of care, payers will see positive developments in population health.

Pillar 4: Streamlining provider and member experience

Member experience and provider experience are both key factors in population health. Bad member experiences -- particularly ones that complicate or reduce access to care -- can dissuade members from seeing their providers or maintaining treatment altogether, and bad provider experiences worsen provider burnout and workforce shortage trends.

Antonucci emphasized convenience and efficiency as integral to positive provider and member experiences. For example, in a conversation with his own primary care provider, Antonucci learned that using ambient listening technologies significantly improved his doctor's work hours by reducing documentation time. The technologies allowed him to focus better on his patients and their experiences.

This doctor's anecdote demonstrates how giving providers the right tools can vastly impact their perspective on their work and improve their capacity to perform well. Establishing a culture that protects doctors physically, psychologically and professionally, that encourages provider feedback and that promotes patient-provider and provider-provider communication is an essential component of positive provider experience.

Payers can empower providers with technologies like ambient listening tools and support and reward organizations that exhibit positive cultures. In doing so, they may accelerate population health improvements.

For those of us that are in the industry, we all experience healthcare for ourselves or for our family and friends. So, looking at it from that lens, I think, is important.

In an incident with a different provider office, Antonucci found that a long wait list and an inconvenient lab location negatively impacted his experience. In contrast to his 20-minute wait time for a car repair or his well-documented primary care visit, his member experience with this laboratory was particularly stark.

Antonucci's lab incident is not an anomaly for members, unfortunately. Moreover, among adult health insurance members who had trouble with their coverage, 50% indicated their insurance problems were not resolved, 28% said the final bill for treatment was higher than expected, 17% never received the care their doctors recommended and 15% experienced a negative impact on their health due to the coverage issue, a KFF consumer survey uncovered.

Antonucci suggested that payer leaders can and should pursue results from a personal standpoint.

"For those of us that are in the industry, we all experience healthcare for ourselves or for our family and friends. So, looking at it from that lens, I think, is important," Antonucci encouraged attendees.

Improving member experience can even be a unifying, value-based care objective for providers and payers who struggle to achieve alignment.

To streamline the member experience, payers should develop ways to ensure that members are up to date on their benefits, understand their health insurance policies and can resolve problems with coverage. Health plans can partner with trusted providers to communicate with members and refer them to specialists. Using omnichannel communication can modernize and revolutionize payers' connection with members. Payers can proactively connect with a member at the appropriate time when their benefits change, instead of relying on the member to notice changes in their explanation of benefits.

Pillar 5: Advancing health equity across the organization

Health equity is a critical element of health plans' population health efforts, cutting across all categories and lines of business. While the status of health equity in the current system is dire, Antonucci saw reason for hope.

"We know that we don't have an equitable healthcare system today. It just doesn't exist. I also would say it's a bright spot in our industry in terms of the focus and the work that I'm seeing there," Antonucci declared.

Improving health equity starts with prioritizing equity within the organization. At Providence Health Plan, for example, the payer's leadership established a chief healthcare experience and equity officer role, a C-suite position reporting directly to the president and CEO that oversees equity across the company.

"Just the simple focus of having somebody that's on healthcare experience and equity in a chief position in an organization like a health plan … it's brought health equity to nearly every conversation that we have in terms of projects that we're focused on, what we're doing, what we're saying 'yes' to," shared Antonucci.

In addition to having C-suite level staff that are strategically focused on improving health equity, payers can influence equity in a number of ways. HCTTF identified four strategies that major payers have adopted to transform this area of their companies:

• Offering infrastructure grants to fund traditionally non-reimbursed provider activities related to improving health equity.
• Appropriately reimbursing based on social risk adjustments for providers with low-income, underserved patient populations.
• Partnering with trusted community-based organizations that are on the ground and well-acquainted with member populations.
• Supporting low-income providers with small financial margins so that they can improve care for their complex, high-need patients.

Payers are well-positioned to improve health equity and should be well aware that better health equity means better population health.

It is easy to focus on just one pillar of population health while missing the whole picture. But payer leaders can augment their impact on systemic, cyclical population health challenges by knowing where their companies stand on each of the five pillars of population health and what they are doing in these areas to make the healthcare system more effective.

Kelsey Waddill is a managing editor of Healthcare Payers and multimedia manager at Xtelligent Healthcare. She has covered health insurance news since 2019.