The face of healthcare in America has undergone a major transformation in recent years. With each iteration of care, the goal has been to do more for less. The underlying financial incentive meant that members received care and services that weren’t always in their best interest.
With each evolution of care, from concierge medicine, to managed care, to care coordination, we get closer to high-quality, high-value care that meets members’ needs.
To fully understand where we are today in the journey, we need to examine how we got here. Let’s take a closer look at the different types of care and the impact for payers and members.
The managed care model was created to centralize member care within a single provider system. The goal was to achieve better health outcomes while keeping payer costs down. However, the main outcome of managed care was that primary care providers were forced into gatekeeper roles to control a member’s access to care.
Members had to see their primary care provider in order to get a referral to an in-network specialist, regardless of quality or cost.
Managed care typically focuses on treating symptoms at lower costs. The idea being that this would be a way to reduce waste through a fee-for-service model. Insurance companies wouldn’t reimburse primary care providers for treatment they were trained to do and had been doing successfully for years. Primary care providers were forced to refer members to specialists. Members would continue receiving specialist care until a new issue emerged. At that point, they would see another primary care provider who would refer them to yet another specialist. Thus perpetuating the cycle of wasteful spending.
Sometimes referred to as luxury medicine, these are private medical services that require a high retainer fee to guarantee care and availability. There can be a significant amount of waste created with this type of care because there are a lot of unnecessary tests and procedures involved. The care is not always in the member’s best interest.
Coordinated Care: the Reboot of Managed Care
Coordinated care takes traditional managed care a step further by viewing care from the member’s perspective. If it’s determined that a member needs additional care beyond primary care, the member’s care team is there to support and closely guide that decision.
Regular follow-up by the member’s care team is also a key component to coordinated care. This ensures that the member is following the care plan and that any concerns can be addressed between visits. With care designed to meet their needs and preferences, members are fully empowered to take ownership of their overall health.
There are a couple of ways that a dedicated clinic delivers coordinated care:
Benefits plan integration
Integrated health coaching
Benefits Plan Integration
Vera’s dedicated clinic model allows for more opportunities for coordinating care because it fully integrates into an organization’s benefit structure. Providers can refer to specialists in-network that are high-quality and low-cost, which reduces costs for payers, employer groups, and members.
Integrated Health Coaching
Health coaches, providers, and staff at care centers are trained in behavior change practices to help them empower members to take ownership of their health. Time-rich appointments allow for meaningful conversations and development of personalized care plans that address the root causes of any health issues. This approach is particularly beneficial for members with chronic conditions whose symptoms can often be alleviated by making positive lifestyle choices.
In a coordinated care environment, the primary care team also follows up to ensure that members got the care they needed and that they have a care plan in place. And, with Vera’s model of coordinated care, the care plan results are provided to the primary care providers, who can then have a holistic view of a member’s care.