“If patient engagement were a drug, it would be the blockbuster drug of the century and malpractice not to use it.” [1]
The ongoing shift from paternalistic approaches to those more respectful of patient autonomy has not magically made patients more accountable for their own health behaviors or more adherent to physicians' clinical recommendations. In the absence of a perfect physician-patient relationship, other external influences can be structured to change the financial incentives and social norms that drive consumer decision making and patient behaviors. Health insurance is often the common denominator between various stakeholders in the health care system, and it is uniquely positioned to improve the health care ecosystem.
Blue Cross and Blue Shield of North Carolina (BCBSNC) has developed a multitude of programs and services to promote patient engagement, primarily through network configuration, plan design, rewards for participation, and other member incentives. But health plans also have the ability to provide incentives to other stakeholders, as described below, to try to achieve greater patient engagement and better clinical and economic outcomes.
Patients and Members
Lifestyle
Most chronic conditions are preventable through healthy lifestyles. Health plans have traditionally offered rewards for eating healthy foods, exercising, stopping tobacco use, and other personal behaviors. The BCBSNC Healthy Outcomes program also includes online challenges, virtual coaching, linkage of wearable fitness devices, and other resources.
Seeking Appropriate Care
Average deductibles and out-of-pocket cost sharing have increased with medical inflation, spurring members to become informed consumers who try to optimize their policies at minimum expense. Tiered and narrow networks drive members to use health plan cost and quality transparency tools. Members can save money by choosing providers with quality designations, such as patient-centered medical homes for primary care and Blue Distinction Centers for “shoppable” high-cost procedures like knee replacements.
Managing Health Conditions
If members have chronic conditions requiring medications, they are certain to incur significant annual costs that can be a barrier to adherence. BCBSNC has published results from our value-based insurance designs, including formularies that waive copayments for maintenance medications used to manage certain conditions, like asthma and hypertension, and deductible waivers for diabetes supplies [2-4]. We send an annual diabetes progress report to any member with diabetes who misses one of the Healthcare Effectiveness Data and Information Set benchmarks, and we offer incentives to close those care gaps.
Employer Groups
The majority of people with commercial health insurance have a subsidized workplace policy. In addition to mandates included in the Patient Protection and Affordable Care Act of 2010, employers have a strong interest in helping their covered members become proactively engaged with their health plan. With some restrictions, employers can create a 30% differential (50% for tobacco status) in the cost of an employee's plan through rewards for achieving certain clinical outcomes [5]. For example, several BCBSNC client groups incentivize or penalize employees who achieve a certain body mass index or who remain tobacco-free. Others incentivize members who engage in BCBSNC wellness programs, disease management, or nurse case management. Some incentivize their employees for obtaining age- and sex-appropriate preventive screening tests or for closing chronic condition care gaps. Some will only pay for certain procedures, such as bariatric surgery, when the procedure is performed at high-quality Blue Distinction Centers. Because employers are quite price sensitive, BCBSNC offers certain clients up to a 5% reduction in premiums for creating a culture of health and for encouraging covered members to achieve threshold engagement rates in various programs.
Insurance Agents and Brokers
A variety of insurance agents, brokers, and benefit consultants help their clients choose plans and engage in health plan programs. They can be incentivized through the commission structure to help their clients achieve these outcomes.
Physicians, Hospitals, and Other Health Care Providers
The current fee-for-service health care system is morphing into a system of innovative value-based reimbursements that promote better clinical outcomes. BCBSNC has created accountable care organizations, patient-centered medical home programs, and care coordination programs to support this change. The Blue Quality Physician Program allows independent primary care practices to earn higher reimbursements by demonstrating better accountability to patients and by improving in areas such as cultural competency. In addition, BCBSNC helps practices by donating electronic medical record software and by consulting with practices on National Committee for Quality Assurance certification. Most provider contracts now have incremental incentives for improving quality metrics. In addition to these financial incentives, BCBSNC shares some of its utilization data with providers to identify and close care gaps and to promote better patient engagement.
Conclusion
Financial incentives are not perfect and do not induce every person to optimize their health and care-seeking behaviors. Also, it is possible to construct incentive schemes that cost more than the savings that could be derived from reducing negative behaviors to their theoretical minimum. However, if they are equitable and thoughtful, incentive schemes can provide an incremental lift over baseline patient engagement rates that may advance the efforts of stakeholders and help members achieve better clinical health outcomes.
Acknowledgments
The author would like to acknowledge Sarah Weiser, PhD, and Dawn Porter, MPH, for their assistance in preparing the manuscript.
Financial support. B.J.C. received no financial support for this article.
Potential conflicts of interest. B.J.C. is an employee of Blue Cross and Blue Shield of North Carolina.
- ©2015 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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