Shifting to Value

Working in the health insurance industry for several years, I have grown accustomed to the various changes—those driven by traditional market forces or by government legislation and regulation—that influence how insurance products are structured and delivered as well as how providers are paid for their care and services.

Our mission at Select Health is to help people live their healthiest lives. To help fulfill the mission, we focus our product development efforts on improving the health and well-being of every member by providing them with high-value coverage that provides access to value-based healthcare.

The shift to value

Much of the health insurance industry has been shifting over the past several years from a fee-for-service delivery model to a fee-for-valueor value-based care) healthcare delivery model. The overall objective of value-based care delivery is to improve the health of a population of people by increasing access to wellness and preventive services; improving the quality of care delivery; and reducing the cost of providing care.

Fee-for-service model

Traditionally, most healthcare organizations have used a fee-for-service model that compensates providers for each appointment, exam, procedure, and treatment they administer, which at times has emphasized the quantity of care over quality of care. Many insurance companies and healthcare delivery systems across the nation continue to use the fee-for-service model. However, the main drawback for this type of healthcare model is that the financial payments are based on providing procedures and services to treat people who are already sick with less incentive toward keeping people healthy.

Fee-for-value model

A fee-for-value (or value-based care) delivery model shifts provider payments in an effort to reward providers for outcomes like patient health and wellness, quality of care and service, and patient/member satisfaction. This model moves upstream from traditional fee-for-service delivery to incentivize members to make healthy lifestyle choices and utilize high-value services like preventive care and regular health screenings for early disease detection and intervention.

At the core, this delivery model emphasizes primary care providers effectively managing patient health and coordinating care with a variety of providers and specialists for more positive patient outcomes. Instead of compensating on the quantity of care, value-based payments are designed to incentivize everyone involved in healthcare delivery to improve member health and wellness to help them avoid needing costly care and services.

The fee-for-value model is motivating those providing healthcare services to reevaluate the best methods for delivering patient care and improve how they are helping their patients.

In health insurance, value-based care is challenging us to frequently examine how our products and benefits are designed. We are focused on helping members receive high-value healthcare services at the right time and in the right setting by reducing and eliminating barriers.

The value-based care approach and product design

Adopting a fee-for-value model guides us in structuring various elements of our plans to ensure access for appropriate care with high-quality providers. With this in mind, we want to ensure our members find value in their health plan, use their benefits, and have the appropriate resources available when making health- and insurance-related decisions.

As we work to improve the value of the products and services we provide our members, we carefully consider several factors that influence quality, affordability, and access to healthcare services:

Federal and state guidelines

There are federal and state regulations that determine in large part how we structure our benefit designs, our coverage policies, and even how we price our products in the market. Each year, we modify our products according to these guidelines, which allows us to stay compliant with the various laws and regulations.

Value

We keep our members' needs in mind as we are designing our products. Through customer research, we better understand the needs of our members and work to modify or adjust our benefit designs to improve coverage for current and future members.

Financial accessibility

We recognize that financial barriers often keep members from seeing their doctor, refilling vital prescriptions, and having necessary exams and treatments that may help prevent illness and disease progression.

As we evaluate our products on an annual basis and look for ways to improve them, we identify opportunities that may reduce or eliminate some of the financial barriers that are keeping members from seeking care, such as lowering or removing deductibles, copays, or coinsurance for high-value care and services.

Value-based collaboration

The fee-for-value model also affects how our provider networks are structured. At Select Health, we partner with providers who are driven to improve the health of their patients and community so that we can work together to keep care and services affordable and accessible.

We work collaboratively with our network providers to align our coverage policies and benefit designs as closely as possible with the evidence-based medicine and clinical protocols they utilize. We also strive to establish networks that contain enough providers in each specialty, so members can conveniently access their providers when they need them.

As our members' needs continue to change, the health insurance market fluctuates, and healthcare delivery evolves and improves over time, we actively evaluate our products to ensure they reflect these changes and help our members access the care they need. Despite the many challenges we can’t control, the fee-for-value healthcare delivery model places our members and their needs at the core of all Select Health’s product development efforts.

Related: Appreciating the Impact of Social Determinants of Health