NOTE:  This blog post was taken from Need to Know: How to Arm Yourself and Survive on the Healthcare Battlefield (2018) by Darwin Hale, COL (RET), USAR, the Founder & CEO of Advocate Health Advisors. Darwin is a respected entrepreneur, author and decorated military officer with more than 30 years’ experience in the corporate world to include serving in the United States Army and Army Reserve (USAR).

Military commanders know that there is a difference between accountability and responsibility. Those words are often used interchangeably, but there is an important difference: responsibility can be delegated and shared, while accountability cannot. Responsibility is an inherent part of accountability, but it can be divided up and delegated to others in the organization.

Think of yourself as the CEO of your own health care. You are accountable to yourself for the results you achieve. You may have experts in place to help you; physicians, pharmacists, physical trainers, nutritionists can all assume responsibility for some part of the effort, but as CEO, you are accountable for the result. Like a military commander, you are answerable for your actions, so choose your expert helpers well.

Besides yourself, that group of expert stakeholders includes providers, insurance carriers or payers, the government and insurance agents. Let’s look at the responsibilities of each stakeholder, starting with the most important – you, the CEO!

You – Taking control of your own health

As the individual involved, there are some things you need to keep in mind. First, there is a lot about health and the health care system that seems unfair, but this isn’t about fairness. This is about taking control of your health. In order to do that, here are your responsibilities:

  • You must assume responsibility for your own wellbeing, becoming an active participant in your own care.
  • You must stay informed because things are always changing. If you have doubts, feel comfortable about getting a second opinion.
  • Keep moving! Utilize movement as well as nutrition and mindset as weapons to fight disease.
  • Establish and maintain access to advisory services that can help you when needed. Are you in a SNP (special needs plan) or other Advantage plan? Do you know the case manager or professional who coordinates your care?
  • Lastly, meet your obligation to care for family, friends, neighbors, and loved ones. Lend a helping hand today; you may need the favor returned tomorrow.

Providers – Coordinating care based on your needs

Providers, the doctors and other health care professionals,are doing great things, working in the best interest of patients despite an inefficient system. Doctors are fighting that system and doing the best job they can with the resources they have. The doctor-patient relationship is sacred, and all the other stakeholders should be trying to facilitate and reinforce that relationship.

The most successful medical-care teams are cross-functional and multidisciplinary. They are organized around patients and their needs, not their own disciplines. Clinicians and other health care providers should not be working in isolation.

In the future, providers will move toward personalized medicine and technology, giving them more time with the patient to focus on the human element of care. They will be more focused on customer and patient service, providing value for the services they provide. They will be organized, connected, and collaborate in real time. This collaboration may be accomplished face to face, or by using internet technology. It will connect the entire health care team to serve patient needs.

Insurance Carriers and Payers – Innovating to improve your health and satisfaction

Insurance Carriers and Payers are now innovating new ways to organize, administer and deliver health care.  They are maximizing prevention and leveraging best practices to produce the best outcomes for patients (that is you)!  They also bring economic rationality to the practice of medicine. We must balance health care and economics, or the cost of medical care will bankrupt our nation. We do not have unlimited resources to apply to any challenge, even to health care.

Private corporations like medical insurance carriers bring innovation, because they have an incentive to bring down costs and to promote choice. Choice is good, because consumers can purchase what best fits their needs, and this leads to higher levels of customer satisfaction. Freedom to innovate means that health care consumers are more satisfied, and medical service is delivered in an economically viable way. At the same time, government requirements for access and outcomes are met. Innovation will produce the best of both worlds, because it plays to the strengths of each.

The medical insurance industry should have these priorities:

  • Innovate, try new ways to organize, administer and deliver medical care.
  • Bring an economic perspective to medical care, achieving efficiencies in delivery and administration.
  • Promote choice and consumer satisfaction.
  • Focus on collaboration in disease prevention and treatment.
  • Evolve disease-state management and rational treatment plans.

Government – Working to protect us and fix our broken healthcare system

The government has started to do some innovative things, like creating “Part C,” the Medicare Advantage program, early in the 2000s. Medicare Advantage plans combine hospital, outpatient care and prescription drug coverage into one program. In recent years, the Centers for Medicare and Medicaid Services (CMS) built upon this success and implemented programs that track provider performance. For Medicare Advantage plans, the CMS operates a “Star Rating System” that provides a quality score to Medicare Advantage Organizations. These plans are rated on a 5-star scale, 5 being the best performers.  Ratings are based on the plan’s performance on selected criteria like:

  • Member experiences, how highly members rate the plan.
  • Customer service, how well the plan handles member appeals.
  • Plan performance, how often Medicare found problems with the plan and how often members had difficulties. This may include how much the plan’s performance has improved (or not improved) over time.
  • Staying healthy, including whether patients got preventive measures to help them maintain good health.
  • Managing chronic conditions How often do patients with certain conditions get recommended tests and treatments to help manage their condition.

The government has a lead role here! All the stakeholders must work together to create an efficient health care system, and even as people understand that the government is inefficient, they also know what it does well, which is to protect us. The consequences of an inefficient, wasteful health care industry touch every American. Only government can coordinate and work with all health care providers, keeping the individual patient’s interests uppermost.

In the future, the federal government should:

  • Continue to foster innovations like Advantage plans and the Star Rating System.
  • Monitor how the providers are doing, allowing consumers to be better able to shop for health care.
  • Ensure that individuals own their personal medical records.
  • Align incentives and pay for performance.
  • Enable consumers to shop for care based on value offered.
  • Offer health awareness campaigns, encouraging people to adopt better health habits.
  • Remove rules that restrict access to care, services, and information.
  • Level the playing field for all Medicare programs. The rules around marketing plans, paying physicians, and hospital admissions vary by Medicare options.

State governments have a role. They can:

  • Work together to allow telemedicine and doctors to practice across state lines.
  • Work to find balance in litigation rules.
  • Continue to work and support those people who are underserved by the health care system.

Local governments can help by:

  • Providing real community interaction with those who need help.
  • Offering advisors available to help people make decisions.
  • Coordinating with the providers to proactively designate high-risk individuals.
  • Orchestrating community-based organizations in their support of healthy living and wellness programs.
  • Focus on preventing slips and falls (STEADI Programs).
  • Encourage citizens to create and share advance directives.
  • Provide type 2 diabetes prevention and other self-management programs.

Insurance Agents – Advising and representing you

Let’s not forget insurance agents! Independent health-insurance agents do a good job of advising and helping people choose plans that are in their best interest. Agents of the future will serve as an extension of an individual’s health care team. They can move even further up the value chain by helping improve compliance, determining if the client qualifies for a Special Needs Plan, and coordinating the in-home health and wellness assessments offered by carriers.

Ultimately, the agent should represent you, the patient, not the health plan. Just as individuals should be able to shop for a doctor, they should also be able to shop for an agent. You want an agent who is knowledgeable and understands the landscape in your community to represent you. They can save you time, money, and misery.

Health care insurance agents should:

  • Genuinely care about their clients.
  • Help clients pick a plan that is right for them and use that plan properly.
  • Assist the care team in assessing the social determinants of health, getting patients into the system for their initial wellness visit.
  • Maximize their in-home presence with the client.
  • Maximize their relationship with the client—the average agent spends several hours a year with each client and can be a positive influence.
  • Help clients connect with resources, services, and benefits.