Ensuring Members Utilize and Understand Their Benefits

^{By Edan Stanley}

Podcast Transcript:

Please introduce yourself and briefly explain your background.

My name is Beth Roberts. I'm the senior vice president for commercial business at Harvard Pilgrim Health Care. And my background, I've been at Harvard Pilgrim for 21 years playing a variety of roles.

Notably in all of my roles, managing what we call P&L, worrying about both how we grow our business, how we make sure that we remain profitable, and how we drive the right health outcomes and quality services for our members.

What role does population health management play in driving value?

Population health is certainly something that Harvard Pilgrim has focused on in our entire journey. It has changed over time. It is certainly a cornerstone of what we do to drive value for both at the health plan level but more importantly for the members that we serve.

When we think about population health at the highest level, we know our health care system is rather complex today. It's somewhat challenging to navigate along the entire spectrum of care.

One of the key things that we can do as we continue to develop and expand our population health role in the entire health care system is become a patient-navigator, member advocate and align ourselves in a partnership way with our member to help bridge that relationship with the physician, the member, and the health plan. 

One of the things that is important and an important role that the health plan has to play is helping members understand their benefits and how to optimize those benefits, so that as they're using their health care system they don't have any surprises.

Most people want to understand what their health plan is going to cover and how, as they make their way to their health care system, what that coverage entails, and what their responsibility is.

From there, it's making sure that people get the care that they need in the best setting for themselves and the right type of care, the first time.

Rather than having to have repeated tests or rather than having a certain type of x-ray and then moving on to another one because the first one didn't say what it needed to detect, it's making sure that the health plan has a role and help navigating, "Okay, here's all the things that are available to you. What is the right thing for you right now?"

We make sure that we're having those conversations with both the physician and the member,  and bridge  any of those gaps that happen in this complex system, so we align  ourselves with the patient.

We also help them with some very basic things like, "Here's some questions that you can ask your doctor so that when you go into the appointment, you're fully informed when you're leaving.” You've asked all your questions. You have a good sense of what's ahead of you in your journey.

We help the member understand their total care plan. The care plan is developed by the physician, but our nurse care managers work with the patients to look very holistically of what is their family's situation, what is their personal situation? Do they have the support they need?

When we look at that person, we can help that patient/member really look at it holistically so that we're helping them fill in the gaps. Let's say there's some food insecurity, we can help identify local organizations that can help bridge that gap so that as the physician is helping them become healthy, we're helping them get access to things that they might need.

It's everything from helping them understand the questions to ask their doctor to helping them determine what their total care plan is, helping them post-hospitalization to understand if they've got a certain set of medications that might conflict with other medications that they have. How do we help them sort through that so they will end in a place of optimal health? 

It's really a partnership model and that's what we're trying to drive most when we think about population health. 

Which areas should health plans and insurers focus on to most significantly improve health outcomes?

Health outcomes, that's exactly what we're trying to impact with population health. One of the most impactful ways that we can get involved is this partnership model. Also, another piece of that is making sure that the physicians and the health plan are working collectively.

One way we can make sure that happens is through value-based contracts where we work with the physician group—or what we call a local care unit, but the contracted entity—to come up with a set of terms that keep our motivations aligned so that as we're helping patients navigate that health care system  we're looking at, again, how to optimally use their benefits. At the same time, making sure that we're keeping costs as low as possible for everybody so that cost as low as possible for the patient, for the healthcare system, for the health plan. When you're in this value-based contracts, that motivation is there.

It's also the motivation is there to help on the full spectrum. Again, not just focusing on the care that that patient needs that day or the next day but looking at the totality of that. 

When you look at the totality of that, helping that member navigate within lower and higher cost systems as well as navigating all of the care in other social elements, looking at that holistically drives better outcomes for both the health plan, the physician, and the patient.

There's one other thing that I want to make sure that I add in here and it's a topic that everybody is very worried about, and that's that intersection of both medical care and behavioral care, behavioral health needs.

In order to look at improved outcomes, back to that holistic approach, we need to make certain that we're looking at the intersection of those two things, and that the care plan includes behavioral health, indications behavior health, potential outcomes as well as medical.

One of the things that we've been working on is rounds that we do with the nurses, both on the medical side and the behavioral health side, where there's a complex case for one of our members or a patient that has Harvard Pilgrim insurance, that the behavioral health nurses and the medical nurses are talking together and coming out with a total care plan, and then really working within the system to help that member navigate.

And we've added digital solutions, where we have a digital solution that allows somebody to engage with behavioral health practitioners to develop a plan of getting better in let's say an eight-week period of time and very regular touchpoints into this digital app that people seem to like.

That intersection is different from when we're thinking about improving outcomes as well.

How can insurance and health plans lower costs while improving care for members?

Some of it circles around some of the things that I've already said like making sure that people understand their benefits. What comes to the forefront for me is there's a lot of different locations that people can access very good high quality, lower cost healthcare at different types of settings.

You see a lot more coming to market where we're trying to encourage people to understand what those settings are and what kind of services can be delivered there. That can lower cost and improve care. It lowers cost in the way of getting them to a system that they have to pay less for and that the health plan has to pay less for. That's on the lowering cost side.

Improving care—when you think of some of these settings, the access is much easier. They can get in sooner. The amount of time they spend at that location is less. It improves outcome at the same time as lowering costs. We see that is an important thing that we can do when either benefits plan design. So when we talk about tiered network products or you talk about incentives to drive people to locations of care that are cheaper, you talk about centers of excellence where it's not only just a lower cost, but the quality is superior to others. All of those things have that double impact of lowering cost and improving care.

It's that whole partner model and bridging that relationship to both our value-based contracts but just generally our relationship with the practitioners throughout our service area in trying to connect the physician to health plan and the provider together.

One that we have a particular passion for is watching for unnecessary care. What I mean by that, it's a little bit of what I said earlier about making certain that when somebody is seeking care, it is the right care that they need. It might not be the least expensive care, but it's the right care for that patient at that time. 

In the long run, that ends up being the most affordable option because they're not experiencing the system in a very fragmented way, but they're getting the right care at the right time and the right setting. Rather than having duplication of tests or radiology, it's really looking for the elimination of unnecessary care. 

Thank you, Beth. Is there anything I haven't asked you about or anything that you'd like to add? 

When we think about all of this, it's emphasizing that tie-in of members being aware and understanding what they have available to them. As much as we can help them understand that at the front end, it makes all of these other population health value-based contracts well-being programs, is that is the cornerstone of getting a member involved early and understanding all that they have available to them. That these nurses are available to them for free, it's part of what they have when they come to Harvard Pilgrim. It is their advocate to help them through this journey.

A lot of people don't understand that. They don't understand that that's a service available to every single member, that is part of their health plan, that they could either self-select into or they may get a call from us because there's something going on that we want to help them with.

I don't think there's a common understanding of that in the industry or from people purchasing within the industry.