Solving health plan challenges: Making better care more affordable


Working with members and providers, as well as behind the scenes, Carelon helps health plans improve the quality of care and lower costs.

Our Chief Growth Officer, John Hastings, and his team work with many of the leading health plans in the nation. In a recent series, we’ve been covering the top challenges that health plans face today. Here, John talks about how Carelon is helping health plans provide better and more affordable care for their members – a top priority for plans today.

Is improving affordability a universal goal for health plans?

Yes. As healthcare costs continue to rise in this country, all health plans are focused on affordability. Rising costs have been caused by many factors, especially our aging population.

As people age, they have more extensive healthcare needs — and more-expensive medical needs. There also have been tremendous strides in technology, and some of that technology — the advanced medical solutions, imaging machines, sophisticated infrastructure — are expensive to operate. In addition, there have been advances in specialty pharmacy drugs, which is wonderful news for people who suffer from certain diseases and conditions. But those drugs can be very expensive to produce.

There are a lot of different forces driving up healthcare costs, and affordability remains a significant challenge for everyone in the industry. Lower costs help ensure that everyone has equitable access to the care they need.

What are some ways that health plans are working to lower the cost of care?

When health plans think about affordability, there are multiple levers at play. First, high-quality care is cost-effective care: creating better outcomes, fewer complications, and fewer readmissions. So quality is a really important factor to drive affordable care.

There is also the safest, most appropriate care for each member: the right settings, treatment, and care provider for that individual — ensuring that their clinical care is backed by medical evidence and best practices.

Next, reaching members and helping them with preventive measures before members develop chronic or acute conditions is another lever. For example, when a member calls in with a question, like how to get a new ID card or how to find a doctor, health plans can take that interaction a step further: they can explore whether there is any kind of gap in care or an opportunity to educate them about services relevant to their specific healthcare needs.

Behind the scenes, health plans can lower costs by improving their operational efficiency. Advanced technology and tools, such as responsible AI, can assist in that goal. Another driver of lower costs and affordability is a streamlined and cohesive payment integrity and subrogation process that ensures claims are paid correctly. When health plans lower costs, it not only helps members, it also enables investments in research and innovation that improve care for everyone.

How does Carelon help health plans drive affordability?

We help address affordability for health plans across each member’s continuum of care. Early in the healthcare journey, we have programs that encompass predictive analytics to identify those people who might turn out to have complex, costly needs. We then pair early identification with very strong engagement programs to get them into care. Once someone is actively receiving care, we’ve created rigorous, evidence-based guidelines and collaborated with specialists, as well as pharmacists and behavioral health clinicians, to make sure that care is clinically appropriate for their situation.

Carelon also addresses affordability by helping health plans improve the quality of care. For example, we offer advanced primary care that involves a very early, thorough assessment of members followed by a highly personalized care plan. Then we follow them throughout the journey of their care. We also support health plan members with palliative care services, which is a tremendous supportive benefit for people in the most complex situations, as well as their families.

Carelon addresses affordability post-care as well by ensuring payment accuracy. There are multiple factors involved in every claim — it's a complex system. For example, there could be another carrier if a claim is work-related or following an auto accident, and you need to ensure there’s no fraud, waste or abuse. Our payment integrity program is AI-driven and state of the art, ensuring that a health plan is being a very strong steward of every dollar.

At the end of the day, lowering healthcare costs doesn’t just help a health plan’s bottom line. It sparks innovation and progress, and it makes care more affordable and accessible for those who need it most.

See healthcare from our perspective

Explore more resources