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Can insurers move the prevention needle?

Sept 18, 2023 |1 minute read time

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With an eye to healthier members, health care payors are increasingly leading a rollout of preventive health care.

Insurance companies have always had a financial interest in teaching members how to stay healthy. For the past decade, prevention has moved to the center of that conversation.

The Affordable Care Act (ACA), which rolled out in 2014, was a national push to ensure that insurance companies (also known as payors) offer a wide range of these services without burdensome cost barriers to their customers. It also “brought access to health insurance and preventive care to so many,” says Cathy Moffitt, MD, FAAP, Senior Vice President and Aetna Chief Medical Officer, CVS Health®.

In all, coverage was extended through the ACA to more than 30 million people* — including record numbers of underserved minorities.* This was “an unprecedented opportunity for preventive care,” says Moffitt.

In the years since, health care payors have also seen a digital revolution and a lifesaving vaccine rollout. Both have shaped how they think about prevention for their members.

Overall adoption of preventive care is still low in the United States. What can payors do for people who are falling through the cracks?

Moffitt: My teams start with the analytics. We find out if members have gaps in their preventive care. We have multiple ways to do that, including reviewing claims, patient charts and encounter data. That’s step one. Then comes the bigger challenge, which is to help get those people to the screenings and vaccinations that they need.

We work with providers. Some of our provider contracts include pay-for-performance incentives that nudge them to keep members’ preventive care up to date. But it’s often the member that needs to make the call, to decide to go in and get the screening or the shot.

We employ several strategies to help make that happen. We might have conversations with a member at an employer’s wellness fair, which can sometimes result in a visit. When a member calls in to get a replacement ID card or to check on a claim with us, we can mention an overdue screening or vaccination. And we have other touchpoints. Medicare Advantage members, for example, have a Healthy Aging support program, and part of that expressly helps them stay up to date on prevention.

Cathy Moffitt, MD, FAAP, Senior Vice President and Aetna Chief Medical Officer, CVS Health, in front of black background

We all understand, first-hand, the profound impact of preventive care. We’ve seen it save lives.

Cathy Moffitt

MD, FAAP, Senior Vice President and Aetna Chief Medical Officer, CVS Health

Cathy Moffitt, MD, FAAP, Senior Vice President and Aetna Chief Medical Officer, CVS Health, in front of black background

Underserved groups have some of the greatest challenges in receiving preventive care. How is Aetna looking at that problem?

Moffitt: Some of those challenges are directly related to social determinants of health (SDOH) — factors like food security, having a home or access to transportation. We’ve come miles and miles in our understanding of SDOH, both as an industry and as a company. At Aetna, we’ve developed new ways of screening for people who might have a need and new ways of communicating that to our providers.

Helping people overcome SDOH barriers is not easy. And it isn’t something that we, as an industry, can do in a top-down way. So, we start by listening, especially to local communities.

We partner with community-based organizations around the country, which sometimes leads to outcomes-based contracts if they can help our members in meaningful ways. We’ve also set up community health councils, which go out and listen to what needs might be most pressing on a local level. In Georgia, our councils have helped start grade school nutrition programs and mini farmer’s markets for seniors. In Pennsylvania, where the community decided that mental health was a priority, we trained 60 local organizations in mental health first aid.

But there are many ways we can do better with the underserved. We know that race, ethnicity, income, sexual orientation and gender identity can all play into trust issues around health care. So, we’ve started to provide information to members that lets them choose a clinician who looks like them, speaks their language or is sensitive to LGBTQ+ issues. Feeling comfortable encourages people to seek care when they need it.

One aspect of prevention is keeping chronic conditions from getting worse. What can health insurers do better there?

Moffitt: We’ve found some evidence-based interventions that work really well. For members with diabetes, for instance, we created an approach called Transform Diabetes Care. At all stages of the health care journey, each member receives a tailor-made invitation to their “next best action” — the step that is going to help them the most. That might be improving medication adherence or engaging in healthy lifestyle choices or something else that stabilizes or improves their condition.

Motivating a member to take those steps might include phone nudges, a face-to-face conversation at the pharmacy or a meeting with a dietitian. The member may receive a glucometer or get help with changing medication regimens, and this can involve a range of providers and touchpoints. It’s all to reduce the complexity of self-management and improve health outcomes. The important part is that we match the intervention with what’s going to help the member take the right next step.

Since the launch of Transform Diabetes Care, we’ve found that 80% of people with uncontrolled diabetes see a reduction in their average blood sugar levels. And we see members in this program taking 26% more healthy actions, which include important things like getting a screening or optimizing medications.

Which frontiers of delivering preventive care seem most promising now?

Moffitt: One durable impact of the pandemic was our big shift toward virtual care. We’re still exploring how that helps us with preventive care. We’re having success with offering virtual provider visits, and when it’s needed, members can also go in person to a CVS Pharmacy or MinuteClinic to get their vaccinations and other face-to-face services. Offering care in those retail settings lowers the barrier for getting this preventive care done.

But within virtual care, there is a much bigger opportunity. We’re looking at wearable devices that can monitor chronic conditions or apps that help members with mood or weight management. Virtual delivery also gives us an opportunity to help people looking for behavioral health care, which is a kind of preventive health care that’s widely underserved. For example, MinuteClinic now offers mental health services in select locations, both in person and virtually, as well as depression screening at all locations. Accessing mental health services in a retail health setting or at home helps improve engagement and reduce stigma.

Another promising evolution — and in a sense, it’s just the opposite of virtual care — is the growth of in-home medical assessments. CVS Health recently acquired Signify Health, which has a network of 10,000 clinicians. They do about 2.3 million in-home visits annually. A provider spends an hour in the member’s home and identifies the member’s clinical and social needs, including missed preventive care.

Home visits are especially valuable for people who lack ready access to primary care, such as those in rural settings or who face obstacles related to their social determinants of health — a lack of transportation, for instance.

As a priority for Aetna, where does preventive care fit?

Moffitt: In my early career, I was a practicing pediatrician. My team has many, many physicians with extensive primary care experience. We all understand first-hand the profound impact of preventive care. We’ve seen it save lives at all stages of the patient journey.

As an insurer, covering preventive care is not only the inherently right thing to do, it’s also a business imperative. National programs that evaluate how well plans cover preventive care — the Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Advantage Star — have tremendous reputational and financial relevance for our industry. As well they should. Several recent steps, including home visits through Signify Health and more options for virtual care, are helping us help our members.

At Aetna, our philosophy and culture require us to hold ourselves and our providers accountable for closing gaps in preventive care. Its value can’t be overstated.

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