Condition-first treatment means changing perspectives
With the exception of an annual checkup, most Americans consume health care when they don’t feel good.
You have a fever, you go to the clinic. You break your arm, you go to the emergency room. You have persistent chest pain, you make an appointment. Maybe your physician refers you to a specialist, and you go—because you’re not feeling just right. You’re not feeling yourself. Something’s up. You have some condition.
You can ask a hundred people to define a health condition and you’ll get a hundred different answers. But for the purposes of this discussion, a condition is something that makes you feel less than your peak. Something you want to improve. Fatigue. Stress. Nausea. Aches. Pains. Weakness.
There are notable exceptions. Pregnancy, for example, can be a wonderful condition.
But conditions are, by and large, why we use health care.
Unfortunately, health insurance plans are rarely designed around conditions.
In fact, despite clever marketing campaigns to the contrary, health insurance plans are rarely designed around the patient.
In the U.S. today, health insurance is primarily designed around big numbers—specifically, population-level statistics and dollar figures. Insurers ask themselves: Statistically, how many MRIs are we likely to have to pay for this year? Statistically, how many people in this patient population are likely to need advanced tests? How many hospital stays are we likely to see?
While it makes sense for a company that is trying to maximize profits, the flaw in that kind of thinking is obvious—it does nothing to improve health outcomes.
Surest is trying a different approach.
Surest is trying to make health care more patient-centered. To encourage more patient-centered care, Surest is designing health plans through a condition-first lens.
Too often when insurance companies measure the way a health plan is performing or how they design a benefit, they think about how much they’re spending on hospital stays, how much on drugs, how much on office visits. But that doesn’t take into account what real people are experiencing. - Tara Bishop, MD, former Surest Chief Clinical Officer
"If I have back pain, I don’t think about how much am I spending on advanced imaging for the year. I’m thinking about the care journey I have to take to improve that condition and reach a good outcome," says Bishop.
Condition-first treatment plans are another way of thinking about putting the patient first.
The patient has a condition, so they’re seeing a provider. What happens next should allow that patient to understand the choices they have in front of them. Their health plan, Surest believes, should make clear from the start the providers, clinical options and medical resources they have available to them—and what those each will cost.
"If we can design a benefit that supports and flexes during the condition journey, it will be more intuitive for a member to understand the things happening as they plan that journey. We’re already starting to see that understanding can drive better value along the way to improving patient outcomes," Bishop says.
Take a patient recently diagnosed with breast cancer, for instance.
Seeking treatment for breast cancer, patients aren’t thinking about how much money they’ll spend on imaging, how much on blood tests, how much on physicians. They’re thinking about what they need to do to get better. How can they improve that condition? What is the path to a good outcome?
Surest ties health care services to specific providers and locations using price.
Analyzing data, Surest sets prices lower for providers and locations that are providing quality, efficient care. This gives members the ability to compare the value of various services and treatments from different providers. The breast cancer patient who decides to pursue chemotherapy might see they’ve been directed to a high-cost provider. On the Surest plan, they can compare providers and prices and may find the same treatment at a lower-cost alternative.
Surest will also provide one-on-one support from a clinical nurse.
The nurse can talk through what the patient should expect, why prices are set the way they are and what the care journey looks like two or three steps down the road. This allows patients to take control of their health care decision-making—and potentially save money.
But most health insurance plans are not designed from the patient’s perspective.
Most commercial health insurance is designed to handle the cost of the thousands of people who will be diagnosed with breast cancer this year. There is little price flexibility in that model, and few chances for members to examine their care options to choose the treatment path that works best for them. There's little focus on improving patient outcomes.
"When you get that cancer diagnosis, you want to know: What are my options? What will these costs? What are the pros and cons of doing each treatment?" Bishop says.
By designing a health plan that allows people to see key decision points and future treatment options—and to understand their potential financial obligation with each choice—we can give them a better sense of control. I don’t think that's ever been tied to insurance before. - Tara Bishop, MD, former Surest Chief Clinical Officer
Surest offers that kind of control by creating a patient-centered care plan, and by focusing on treatment paths and options for improving specific conditions those patients encounter. Sometimes it's as simple as helping patients find high-quality providers for each condition.
Finding the right provider
"How do they know who the best doctor is for a specific condition?" says Surest Chief Health Officer Marcus Thygeson, MD. "There are lots of gastroenterologists out there. Some are good at treating inflammatory bowel disease, others are better at pancreas or liver problems. We want to be able to help our members find the right providers, treatments, services and programs to help reach a better outcome."
"As a plan, we need to understand that’s what our members are solving for. Traditional health insurance plans are built around financing for physicians, hospitals and drugs. Surest is set up to figure out how to improve your condition in a way that is inexpensive while providing a good health outcome." Thygeson points to diabetes as an example.
Diabetes patients exist at different points on a spectrum as their treatment paths unfolds. Some diabetes patients want to try to reverse the disease. Some are simply trying to manage blood sugar levels. A health plan should be flexible enough to help patients find the providers and services that are best for them at every point along the spectrum.
"I think about it longitudinally," Thygeson says. "Where are the key decision points, the places where I can help people the most? Other health plan designers think in terms of managing risk. At Surest, I’m thinking I have a lot of folks wrestling with this condition, at different stages of the condition, with different needs. How can I provide them all with resources to help them reach their health goals?"
Most health plan designers, Thygeson says, think patient engagement is about getting people to participate in programs that help manage the financial risk of insuring a population with a wide range of medical conditions. Surest approaches conditions from the standpoint of trying to ensure members know about different resources and tools—like new ways of delivering care—that can help them reach better health outcomes, while saving money and finding affordable care.
The approach works for plan sponsors as well.
Typically, health plan administers make profits by building a margin onto medical expenses. They focus on cost trends. If year-over-year health costs rise 10%, that’s a 10% trend. If costs are trending upward, margins and profits trend upwards, too. Surest believes that by reducing waste from the system and building plans around conditions, negative trends are attainable. In other words, health care costs might go down for plan sponsors year-over-year. Early numbers, Thygeson says, are promising.
We’re showing substantial negative cost trends for some of our plan sponsors. We know we’re reducing only some of the waste in health care, so we think we should be able to deliver a negative trend for multiple years as our plan design gets even smarter. - Marcus Thygeson, MD, Surest Chief Health Officer
It seems like a small, subtle thing, changing a viewpoint to focus on condition-first plan design. But the impacts benefit both plan members and sponsors. And it’s part of a larger effort at Surest to fundamentally change—and improve—the way people consume health care.