Health Plan Innovators Focus On Clinical Outcomes

by Rahul Dubey & Shahid N. Shah

March 20, 2017

Historically, health plan innovators have often sought increased productivity in claims processing, more efficient call centers, or enhanced payment options. More recently, health plans find that in addition to working on internal productivity, it’s important to identify and fill care gaps for their members.

Consumer-centric innovations such as providing tools to engage members in their own care, enabling providers to better coordinate care, and collaborating with providers to improve members’ clinical health outcomes, are gaining momentum. The idea of improved clinical outcomes, something long thought to have been in the purview of health systems and other providers, is now considered to a be a worthy and achievable health plan goal.

As some of the most innovative plans have discovered, the relatively simple issues like data capture and normalization, have been identified and improved already. The more challenging issues, namely what to do with the data they’ve stored and cataloged for years, has yet to be achieved widely across the industry. Some health plans, such as the Group Health Cooperative EC (GHC) in Wisconsin, have figured this out and are working to find impactful consumer-focused solutions. Plans realize the next wave of innovations, likely with the highest payback, will come from multi-stakeholder and multi-institutional, evidence-driven innovations where payer, provider, care management, and disease management work together for a specific individual’s clinical outcomes.

During a recent AHIP Innovation Lab Solution Working Group (SWG) in Chicago, GHC Chief Medical Officer Dr. Michelle Bauer highlighted the critical importance of studying a patient population to holistically understand how an individual’s clinical needs are directly tied to cultural, familial, environmental, and financial factors. Health plans like GHC recognize that even for common chronic conditions, like diabetes, they must first assess the underlying causes, such as obesity, and establish multi-faceted communications and innovations to treat the root of the condition versus just the symptoms. The struggle, even for the visionary innovators, is that many causes of common conditions are complex and the evidence necessary to address them is difficult to gather and measure results.

So, what can health plans do when a population health problem doesn’t have a single solution? Dr. Bauer said they aren’t giving up. They’re finding solutions for seemingly intractable and prevalent problems like obesity.

Through its work at the AHIP Innovation Lab, GHC and Health Management Resources (HMR, a subsidiary of Merck’s Healthcare Services and Solutions) could establish a direct link between weight loss (obesity specifically) and complex societal problems that require the following guiding principles:

  1. Demonstrate clinical outcomes. Programs that provide better glucose control, better lipid profiles, lower blood pressure, and less joint-bearing issues such as knee replacements, have a higher probability for sustainability.
  2. Tie clinical outcomes to lower costs. Obesity management and prevention of some chronic conditions should lower clinical costs as well as reduce (or in some cases eliminate) the need for medications used to treat associated conditions.
  3. Put providers in charge with effective reporting tools and hold them accountable for results.  There’s a need to equip clinicians with easy ways to engage their patients and refer them to effective programs.
  4. Foster enduring behavior change in consumers. Health plans must help consumers acquire the skills to adhere long-term. For example, learning how to select and eat healthy foods, reducing a sedentary lifestyle and adding exercise as a routine to their daily lifestyle.

As Dr. Bauer noted, health plans are in the business of managing the health risks of our members. “We do a good job of identifying patients with problems like obesity but we’re not always good at solving those problems using an evidence-based approach,” she said. “As we get better at identifying the goals we’d like consumers to achieve, we need innovation partners to work with us and our members to prove – through share risk models – that real outcomes that our members can see and feel are achievable. I’m impressed with HMR’s focus on clinically proven weight loss solutions that we can offer to our members to help pre-diabetics from getting diabetes and diabetics from deteriorating their condition.”


To learn more about effective clinical weight loss intervention, please visit the information on Merck’s HMR program here.