According to a 2023 Harris Poll survey, the majority of Americans give the U.S. healthcare system an average or below-average grade.
While factors such as access to insurance coverage and a lack of primary care providers were on the list of complaints from respondents, the overwhelming complaint (61%) was affordability of care.
This problem of affordability has very real consequences, as the same Harris survey found that 44% of respondents had recently skipped or delayed care they needed due to costs.
It is in many ways a vicious circle. The more people avoid receiving care, the more likely they are to need more expensive care down the road. And this cycle has created a healthcare system where we can see from apree health data that 89% of the spend came from less than 12% of the population. In fact, of those members in the top 12% of risk had an average of $45,000 in claims cost per year.
That’s simply not sustainable. But in order to right-size the cost of care and the industry as a whole, we need to move away from the current healthcare model that favors volume over quality and replace it with one that encourages people to consistently seek care well before they may have a health problem.
In other words, we need to increase the regular utilization of primary care.
The model for lower costs
At apree, we break down our populations into three segments:
- 1. High and rising risk – we have found in our data that the average per member per month cost for people in these two groups is $1,800.
- 2. Hidden risk – this group may be healthy or may have conditions undetected due to a lack of engagement in their healthcare or skipping yearly visits.
- 3. Well-being – this is 60% of the population but the least amount of cost to an organization.
As an industry, the goal should be to reduce the number of individuals who move to the high and rising risk population segments. That means boosting patient engagement in their health and encouraging patients to proactively seek care well before their problems become acute and more expensive procedures and/or specialty care become necessary.
Simply getting people to visit their doctor regularly is not enough, however, since the current churn-and-bill primary care model is designed to assess and treat patients as quickly as possible.
Instead, an entirely new primary care model is needed. One that is based on quality of care over quantity and is focused on helping people lead healthier lives.
That model is value-based care, which the peer-reviewed journal NEJM Catalyst has summarized as a “healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes.”
This focus on patient outcomes has far-reaching benefits, including:
- Reduced emergency room visits, specialist care, and high-cost procedures, reducing their financial burden
- Higher quality and patient engagement for providers, allowing them to spend less time managing chronic diseases and reducing the financial risk inherent to the current capitated payment system
- More control of costs and less risks for employers providing health benefits to employees, since a healthier workforce leads to fewer claims and less drain on resources
- A reduction in overall healthcare spend in society due to less money being spent helping people manage chronic diseases, costly hospitalizations, and medical emergencies
Value-based care in action
When we talk about value-based care, we’re not talking about a theory. It is the foundation of our Advanced Primary Care (APC) model, which was developed in 2012 and implemented across our care delivery network five years later.
Since APC has been in place, we have been able to improve outcomes and reduce costs for not just patients but employers and providers as well.
Benefits for patients
- Whole person care – Providers move beyond symptom management because they have the time to explore the underlying issues beneath those symptoms, including physical issues and all the social determinants that affect health. Once these are uncovered over time, a plan can be developed to address them.
- Significant cost reduction – When APC is backed by an employer or provided by a payer as part of a health plan, care is then delivered at little to no cost to the patient. That’s a huge benefit, especially at a time when many patients ignore their health because they can’t afford treatment or defer care due to high co-pays or deductibles.
- Individualized, efficient support – The APC model also helps patients experience the best of both worlds: the resources they need for a healthy lifestyle and healthcare that doesn’t bleed them dry.
Benefits for employers
- Reduced healthcare costs – When self-insurers pair with APC, they gain more control over their benefits and plan design, reclaim consistency over a key part of their balance sheet, and retain lower overall costs of care. This helps employers avoid a cycle of increasing healthcare costs that forces them to choose between reducing benefits or cost-shifting to their workforce to stay solvent.
- Increased productivity – APC’s proven results lead to healthier employees, and healthy employees are happier, more present, and more engaged in their workplaces. APC also empowers and educates employees to take greater ownership of their health goals with the support of a primary care model focused on preventive health and improved well-being.
- Improved health outcomes for workforces – Employers who decide to implement APC with the help of a proven partner can dramatically enrich the healthcare benefits they provide, improving health outcomes while also flattening the curve of their benefits costs.
- Better talent acquisition – Today’s workforce (the largest percentage of which is made up of Millennials) is looking for healthcare options that are convenient, meaningful, and focused on their holistic health. APC allows employers to provide just that and, as a result, gain a competitive recruiting advantage.
Benefits for providers
- Ability to focus on quality, not production – In the APC model, financial incentives are based on the quality of care provided, not reimbursement for procedures. There’s no reason to rush through as many appointments as possible over the course of the day. As a result, providers spend more time with each patient.
- Operating at the top of their license – Because APC focuses on providing 80-90% of care in the primary care setting, providers are encouraged to do more than simply serve as a gatekeeper to specialty care. They become the key medical provider to their patients, using the full scope of their training and skills to build relationships that drive improved outcomes for their patients.
- Improved support – In addition to having more time with patients and the incentive to provide whole healthcare to their patients, care teams also have the necessary support. At apree, care teams are structured with health coaches and allied staff members supporting providers. Whole health coaches, who are experts in behavior change, and behavioral health professionals also offer additional support, helping patients with behavioral or mental health concerns.
Better care at lower costs is possible
In a country as innovative, influential, and wealthy as the United States, healthcare simply should not receive poor grades from its people.
But if we’re going to turn things around as a nation and build a healthcare system that works for everyone — from patients to providers, employers to payers — then we need to tear down the current model and replace it with one where prevention is the primary focus.
We know what that model is, now we just need to make it the standard one.
