Why do half the people who need healthcare opt out, choosing not to utilize their healthcare benefits? It’s the foundational question that, despite recent expansions of employee benefits offerings and the litany of digital health point solutions, continues to frustrate benefits managers and their employers. My career experience with both healthcare provider systems and healthcare plans tells me that it’s a problem of structure affecting behavior. And we’ll never change member behavior until we fix the structure.
The history of trying to build a better health and care experience to engage consumers has been like using scavenged parts for a ship bound for rough seas. People have done the best they can with limited resources, but that has been inadequate for surviving the elements.
Aggregators — who focus on reforming healthcare payment models — lash fragmented pieces together to simplify employer billing, but that doesn’t touch the member experience. Navigators — who help connect members with disjointed digital health points solutions and a controlled network of care providers — don’t solve for the issues of care quality, cost, or choice, essentially directing people to board a broken boat.
While not the only reasons why members get frustrated and opt out, these are large, overlooked areas.
A Choppy Sea
Healthcare remains a mess. Nowhere else would consumers have to endure the incompleteness of the product. You wouldn’t purchase tickets for a voyage on an actual ship that was missing its engine or crew, but that’s exactly the healthcare system offered to consumers. The half of the member population who need care but are discouraged by the prospect of sailing on a sinking ship and decide to stay on land, are too often outside of our view. Healthcare reformers focus on the cost of care — understandably; healthcare is the number one cause of personal bankruptcy.
But we don’t pay enough attention to the impact of cost and confusion on engagement, dissuading people from seeking care or settling for inappropriate care. When we talk about underserved communities, aside from addressing race, ethnicity and gender, we need to recognize that the population that opts out of care is from every geography and economic class.
To better understand “underserved populations” in healthcare, we need to start by examining who isn’t getting the care they should. The barriers to good, appropriate care are what’s keeping people from utilizing the system, not necessarily a lack of benefits. Ironically, there’s actually a convergence of healthcare inequity and benefits fatigue that lead different people to the same destination — opting out.
The cause of that disengagement is structural.
Building a Better Vessel
“Transparency” isn’t a new concept in the battle to make healthcare work for more people. But, despite its recruitment in the service of multiple challenges, it remains the vital port from which all patient journeys must be launched. Consumers want one thing: make it simple.
Healthcare is complicated, and to clear the horizon for safe passage, we’ll first need to identify the largest obstacle: the entities that benefit enormously from the status quo, a model centered on profitability from claims volume instead of revenue tied to health improvement and efficiency. In fact, much of the legacy industry’s profits are linked to our morbidity and mortality — and we have to be honest about that.
There is approximately $1 trillion of waste in our $3 trillion healthcare system, with little incentive for the groups profiting from the systemic dysfunction to change their business model. United Healthcare reported $17.3 billion in profit in 2021. We can’t look to companies like that for “consumer-centric” change. That’s not how they’re structured.
Building a better model requires making transparency directly available to the consumer. Only true transparency — of quality, cost and access — will establish integrity across the entire arc of care, and only integrity will help engage people in the system. For example, the “Shoppable Services” legislation that CMS and others have adopted forces providers to publish prices of certain procedures, which should be helpful.
Unfortunately, the way the line-item costs are published is confusing. Consumers want to know what the all-in cost of a service will be and whether any of it is negotiable, not just the pieces and parts that are difficult to understand.
The Hybrid Ship
More than anything, simplification in the service of transparency can solve the opting out problem. The historical response to the call for simplicity, though, has been weighted towards technology. Our technological advances are remarkable, but technology alone can’t be the simple button consumers reach to push. It doesn’t have the qualities to bring people back into care. Technology won’t get to integrity by itself.
Cutting through the noise requires a hybrid model — where people guide other people through the technology — that is hyperlocal and is structured around two member deliverables:
- Finding the appropriate care wherever it is — in your community when you don’t need to travel; other locations if you are in a desert of care for your need; in your own home when it’s sufficient.
- Providing reliable information, clearly, to get the member to trust their own ability to make their best decision.
The solution is coming from new companies who have a clear slate, and a clear path, to build the hybrid ship. The traditional players are stuck in drydock — exactly where they want to be, and where they want to keep members. To launch a new vessel for a better journey, the solution is rising from companies that are free from the burdens of old business models, that have the latitude to truly embrace the guiding principle of member equity.
Only with their ascension will we be able to welcome all passengers on board.
Tanya Dillard is the Vice President of Strategy and Innovation at Transcarent, a new and different health and care experience for employees of self-insured employers.