How Payer Programs Promote a Healthier Lifestyle for Members

As adults, we know the importance of eating healthy foods, including those green vegetables of which not everyone is so fond. We were taught as children to eat from the recommended food groups and to avoid excessive portions. But do we always follow those guidelines? For many of us, the answer is a big “N.O.”

Unfortunately, poor diet and lack of physical activity are among the reasons a higher number of Americans have at least one chronic disease. Not only does chronic disease directly impact quality of life and result in morbidity and disability, but it also represents an enormous burden to the United States health care system. Approximately 90% of the nation's $3.5 trillion in annual health care expenditures are devoted to treating chronic conditions.

According to the American Academy of Family Physicians (AAFP), lifestyle changes have been shown to markedly lower morbidity and mortality rates for most chronic diseases. Based on this principle, many health plans have established various programs to promote healthy lifestyles for their members. By doing this, they aim to improve their members’ health while reducing the need for costly utilization of health care services.

Comprehensive resources

In addition to wellness programs, some payers offer and promote extra preventive services, medication adherence strategies and other various forms of patient education. Research proves that members who are pleased with the service they receive will apply that contentment to loyalty to their health plan.

Wellness programs

As noted on HealthCare.gov, wellness programs allow plans to offer members premium discounts, cash rewards, gym memberships and other incentives for participation in smoking cessation, diabetes management and weight loss programs. Other focus areas in these programs are nutrition education, stress reduction resources, mental health assistance, risk assessments and health screenings.

Researchers from Harvard published information from 22 different studies that looked at wellness programs and health care costs. The studies found that the average return on investment was $3.27 for every dollar spent on the program. A study from RAND Corporation found that payers saw successes in smoking cessation, diet plans and exercise regimens when members completed their wellness program. For workplace wellness programs, experts point to health premium reductions as the most effective incentive for persuading employees to participate.

Preventive services

The Centers for Disease Control and Prevention (CDC) has reported chronic diseases that are avoidable through preventive care services account for 75% of the nation’s health care spending, which cuts annual economic output in the U.S. by $260 billion.

Payers are required under provisions in the Affordable Care Act (ACA) to provide preventive services such as screenings, tests and health evaluations at no cost when consumers receive care in specific provider networks. However, offering them as beneficial rather than necessary could positively affect health care spending and utilization.

Medication adherence

Health plans are challenged with helping their members get access to necessary medications while keeping prescription costs down, even as medication prices continue to climb. They also encounter increased member spending in the form of medication nonadherence, which leads to poor outcomes and increased health care service utilization and costs.

An estimated $100-300 billion annually in avoidable American health care costs has been attributed to medication nonadherence. By educating members with chronic conditions on the importance of medication adherence, health plans can promote improved clinical outcomes.

Mental health

Mental illness is a prevalent but not frequently discussed issue in the U.S. The National Alliance on Mental Illness (NAMI) reports that one in five adults experience mental illness each year. Many individuals dealing with a mental illness don’t seek treatment for it, partly due to the negative stigma and cost of care.

A JAMA Open Network study found that Americans were paying for out-of-network behavioral and mental health care services at a higher rate than paying for any other kind of out-of-network care. Payers that incorporate mental and behavioral health care reimbursement through value-based models can better align incentives with their behavioral and mental health care partners.

Patient engagement

Engagement initiatives are an essential part of payers’ strategies for more healthful members because they encourage them to take an active role in their health care. Such initiatives also can be utilized to improve member satisfaction and quality ratings, increase member loyalty and retention, maximize reimbursement and promote more efficient use of health care resources.

Research has linked higher levels of patient engagement to greater use of preventive care; lower rates of smoking and obesity; less delay in seeking care; greater awareness of treatment guidelines; better clinical indicators (e.g., cholesterol levels, triglycerides, depression); lower use of hospital and emergency care; and decreased hospital readmission rates.

Learn about the services that AMR provides, or contact us to find out more.