How Do Payers Balance Personalized Care With Population Health?

Bruce A. Feinberg, DO: Payers are caught in this limbo area of thinking about population health but being responsible at the patient level—which is your member, your crowd.

Ira Klein, MD, MBA, FACP: Yes.

Bruce A. Feinberg, DO: So how do you balance the 2 when you start to think about value and cost?

Ira Klein, MD, MBA, FACP: When I was on the payer side, we knew all of the rules regarding our various patient populations—commercial, who was fully insured; commercial, who was self-insured by [their] employer; and Medicare and Medicaid, and the rules of the government. We knew what was going on in those worlds and how we could try to pull levers to get more value for the care that we were providing, both in the population health base—for example, cardiovascular disease—and the high-cost, low-incidence diseases like cancer. In the commercial population, about 6 per 1000; Medicare maybe about 4 per 1000. And that leads to different strategies.

For population-based care, you can really implement value-based insurance design because the treatments are not expensive and you can remove some of those barriers without hurting anyone’s bottom line. And you can impact a lot of people who get it. It’s not a difficult equation to say, “I’ve had a heart attack. Now my ACE inhibitor and my beta-blocker are free.” Okay, more people are going to take ACE inhibitors and beta-blockers. I totally get that.

With the high-cost, low-incidence diseases is where we struggle. Because 5% of the population typically incurs 50% of the cost, the solutions have to be more personalized. At the same time, as Mike pointed out earlier, the decision maker is often not the patient. Then, as Alan said, it’s often the system. The reason being, the disease is so complicated that you often need to have the decision making made primarily by the provider or the provider group.

That leads you into the types of programs, like oncology medical homes, where you say that the patient’s really not going to be able to pick one of those 16 NCCN [National Comprehensive Cancer Network] regimens for a HER2—negative, node-positive, breast cancer. But, if I have a provider practice that signed a contract that says they’re going to use a narrowed portion of evidence-based medicine, then I kind of delegate that value to the practice. All I have to do is create an insurance design that creates a tiered network so that more patients will go there. And then I’ve tried to solve that by doing sort of a network model and delegating responsibility, and maybe some upwards and downwards risk to the provider group.

That’s how I’ve looked at it on the payer side. On the pharmaceutical side, it gets a little more complicated because “nobody pays retail.” So what’s being touted out there as cost is not actually the real cost. And when I think about the hierarchy of what I would want to eliminate to create more efficiency in the system, I’m not so sure I’d want to take a swing at the innovators first because there’s so much grit in the machine that there’s a lot of other things we can do to lower cost.

We didn’t talk about that political third rail. That’s a little less electric, but still is what we are doing with medical futility and care that’s given at the end of life. We haven’t really talked about why there are such low enrollments in clinical trials. And we haven’t talked about why people are hogging their data and locking it up in safes and not allowing innovation to move quicker. So I would rather take swings at those elements of the system that need to be fixed than something that involves a price that’s not actually the price.