Advanced payment models are designed to align reimbursement with the desired outcome of value (quality, service, and cost) for individuals. However, our current insurance models do not account for the desired short-term financial outcomes aligning with the much longer duration of care which is necessary to see clinical improvement.
For example, to prevent heart disease, cholesterol management requires payment for long-term medication and yet, the payer for the treatment is not the recipient of the cost avoidance that will occur. This situation occurs because we seek investments for short-term payback when the outcomes require numerous years to achieve fruition.
When one is younger, insurance is usually employee-based with the financial risk being born by the employer. However, since the average time a member remains with an individual employer is only 2-4 years, there is little incentive for long-term investment by the payer for health and wellness since they will not see the financial results before that employee moves on. As a person moves from employer/payer to employer/payer, over time, one would assume that it all evens out; however, we do not view it through this lens; instead, we examine results on an annual budgetary basis which is inadequate.
Therefore, we must solve for these issues if we wish to align investments in health with the desired long-term outcomes. Should Medicare pay for specific treatments in non-Medicare members? If insurance is portable, a health plan would be better incensed to invest in the individual because they have a possible longer horizon of coverage. Furthermore, employer groups need to understand that their investments impact other employers, and the reverse is true as well.
Considering that the cost of healthcare impacts all citizens, we must advance our solutions towards a more systems approach. This direction will require understanding the effects of time on disease improvement and prevention and the coupling of our present insurance and employment models. If we sincerely desire advancement, we must marry all the different dynamics together in an approach that benefits the individual and the entire healthcare ecosystem simultaneously.