People struggle with the U.S. healthcare system, and there is opportunity to improve the member experience nearly every step of the way. From choosing a health plan and finding a convenient in-network doctor, to following a care plan, to understanding medical bills and what’s covered, roughly seven in 10 people say the American healthcare system is hard to navigate.1
For some, difficulties crop up as soon as they try to access care. People living in rural areas often have to travel much farther than those who live in more urban areas.2 Lack of transportation and high-speed internet, as well as shortages of healthcare workers, pose real challenges.3,4,5
For other people, cost worries keep them from seeking care in the first place. More than half of American adults have avoided the doctor because they were concerned about the cost.6 When people put off regular checkups with a primary care provider (PCP), they miss out on the benefits of primary care, such as:7
- Catching health problems earlier when they are easier to treat
- Preventing problems with immunizations as well as general health advice
- Managing chronic or complex conditions
Another issue, is that people get care from an array of locations, leading to a disjointed care journey that includes specialists, hospitals, after-hours clinics, home care professionals, and even social service agencies. This can become even more difficult during care transitions. Communications between providers can become more fragmented and less coordinated. Less than half of primary care doctors say specialists communicate with them about changes to their patients’ medications or care plans.8 This leaves people vulnerable to adverse medication interactions, conflicting or confusing directions, and unmet needs.
People with serious or chronic conditions bear the brunt of a fragmented care journey. Especially for them, care fragmentation leads to:9,10,11
- Gaps in care
- Unnecessary testing and procedures
- More emergency department visits
- More hospital admissions
- Higher costs
- Lower satisfaction
Healthcare lags behind other industries in providing the tools and services needed to help constituents seamlessly navigate. We have an opportunity to bring together a better experience to improve experiences and outcomes, and costs.
Our perspective: care works better when it’s connected
How health plans are making a difference
At the intersection of patients, providers, and employers, health plans have a key role to play in building an ecosystem of connected care. In fact, leading plans already are finding ways to ease the experience and reduce fragmentation across the health system by:
Social drivers of health (SDOH) have become part of the national dialogue, and removing barriers has a place on many health plans’ priority lists.
To identify members in need, plans are now integrating SDOH programs within increasingly sophisticated home-based care management models. Leveraging the growing trend toward home care, plans have an opportunity to connect more members to resources that address needs for food, transportation, and other barriers.
New platforms connect stakeholders-care management, multidisciplinary care providers, pharmacy management, and social services, creating a model that offers a more seamless experience for payers, providers, and members alike.
Health plans are using advances in telehealth to make it easier for people to look for medical and behavioral health care from the comfort of their home, or even while traveling.
Plans are now extending the virtual care concept through a virtual pharmacy model that:
- Connects members with pharmacists for consultations
- Allows members to indicate their preferences regarding how their medications are packaged and when they are sent
- Integrates with member health records to address care gaps through reminders of overdue lab work or preventive care
Health plans are further enhancing convenience through new platforms that provide healthcare stakeholders with a more seamless experience across a spectrum of connected care options–digital, virtual, in-person, and at-home.
Addressing the intersection of physical and behavioral health
Increasingly, plans are taking a more holistic view of members. They’re now employing new behavioral health models that coordinate medical and behavioral case management across members’ journeys from intake, to treatment, to aftercare.
Plans also are using predictive modeling that mines health and prescription data to identify at-risk members and connects them via omnichannel outreach to treatment programs based on their specific needs.
They’re further enhancing access to behavioral healthcare through a “no wrong door” referral model that includes concierge programs, self-referrals, or referrals from community providers and other sources. Some embed behavioral care management in high-volume inpatient and outpatient facilities.
Creating high-touch, high-tech care models
For those with complex or chronic conditions, plans are helping to prevent hospitalizations, ER visits, and improve outcomes by replacing traditional care models with new approaches. High-risk members greatly benefit from an intensive, highly personalized model that’s tech-enabled and provides round the clock support. Through this model, care teams engage members where they are, via clinics, telehealth, text messaging, and other channels, coordinating care with their primary care providers.
For members with specialized needs, such as those with cancer, plans are using dedicated concierge programs that guide them to the right care via virtual second opinions, centers of excellence, and devices that monitor their conditions remotely.
Access to dedicated care navigation programs helps LGBTQ+ members connect with professionals with specialized expertise in areas such as hormone therapy, fertility, and gender affirmation surgery.
Members with advanced illnesses receive access to home-based and virtual palliative care programs offering the right level of physical, behavioral, and spiritual support for themselves and their families.
For all members, but especially for our most vulnerable populations, as well as their care providers, health plans are finding ways to create better connected care experiences. Advances in technology combined with a “people-first” orientation are helping to reduce fragmentation for all stakeholders.