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Compliance-driven Health™

Consumer-driven Health (CDH) was a fatally flawed concept from Day One.  The idea that a layperson could somehow improve their own clinical outcomes and lower costs by taking advantage of sponsored online medical resources is a stretch of the imagination at best – especially when that person might be facing a new diagnosis.

Further, the purchase of healthcare services is unlike most other consumer purchases in that there is no logical motivation for a patient to select the least costly provider of service.  In fact, the assumption is often that the most expensive provider must be the best.  And when it comes to our health, the quality of care can be a matter of life or death.

The fact is that the average healthplan member lacks the necessary clinical expertise to direct and manage their own healthcare – particularly when the member is struggling to understand a newly diagosed disease.  Consequently, offering a benefit plan which “rewards” consumerism is unlikely to achieve any measureable savings.

The better approach is to reward plan members, both healthy and diseased, for being compliant patients.  Healthy plan members should be incentivized and rewarded for following accepted preventive care/wellness protocols like routine physical exams and diagnostic testing.  Diseased members will be rewarded for accepting the support of the healthplan’s disease and case management functions which serve to ensure that appropriate clinical protocols are followed.

Under a HIPAA Standard-based Wellness Program, plan members can be rewarded by as much as 20% of the total cost of the healthplan.  This total varies by the tier or coverage level.  For example, if the annual Family premium (or premium equivalent in a self-funded plan) is $10,000 then the amount of the reward can be as much as $2,000 – a sufficient amount of money to motivate plan members to be compliant with wellness and disease management protocols.

Why the focus on compliance?  A recent study revealed that the average compliant diabetic in a working population incurred just over $3,000 in annual claims whereas the average non-compliant diabetic incurred more than $15,000.  This $12,000 difference was not a factor of the type of disease, its severity or the patient’s access to quality healthcare providers.  The difference was attributable entirely to the compliance of the patient.  Which begs the question, “Is it fair for a healthplan to treat these two patients equally?”  Wouldn’t it be more fair for the compliant patient to pay less out-of-pocket as a reward for doing “right things”?

Healthplans in the future will vary the level of benefits based on the willingness and commitment of plan members to do these right things.  And doing those right things will lead to improved health outcomes and lower costs – not just for the healthplan overall but for the compliant patient too.

“Compliance-driven Health™” – you heard it here first.

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