This One Weird Trick Can Fix U.S. Healthcare

By OWEN TRIPP

Creating a healthcare experience that builds trust and delivers value to people and purchasers isn’t a quick fix, but it’s the only way to reverse the downward spiral of high costs and poor outcomes

Entrepreneurs like to say the U.S. healthcare system is “broken,” usually right before they explain how they intend to fix it. I have a slightly different diagnosis.

The U.S. healthcare system is the gold standard. Our institutions and enterprises, ranging from 200-year-old academic medical centers to digital health startups, are the clear world leaders in clinical expertise, research, innovation, and technology. Capabilities-wise, the system is far from broken.

What’s broken is trust in the system, because of the glaring gap between what the system is capable of and what it actually delivers. Every day across the country, people drive past world-class hospitals, but then have to wait months for a primary care appointment. They deduct hundreds for healthcare from each paycheck, only to be told at the pharmacy that their prescription isn’t covered. While waiting for a state-of-the-art scan, they’re handed a clipboard and asked to recap their medical history.

This whipsaw experience isn’t due to incompetence or poor infrastructure. It’s the product of the dysfunction between the two biggest players in healthcare: providers and insurers, two entities that have optimized the hell out of their respective businesses, in opposition to one another, and inadvertently at the expense of people.

Historically, hospitals and health systems — including those 200-year-old AMCs — have dedicated themselves fully to improving and saving lives. I’m not saying they’ve lost sight of this, but until recently, margin took a back seat to mission. With industry consolidation and the persistence of the fee-for-service model, however, providers’ hands have been forced to maximize volume of care at the highest possible unit cost, which in turn has become a main driver of the out-of-control cost trend at large.

This push from providers has prompted an equal-and-opposite reaction from insurers. Though the industry has been villainized (rightly, in some cases) for a heavy-handed approach to utilization management and prior authorization, insurers are merely doing what their primary customers — private employers — have hired them to do: manage cost. Insurers have gotten very good at it, not just by limiting care, but also through product innovation that has created more tiers and cost-sharing options for plan sponsors.

Meanwhile, healthcare consumers (people!) have been sidelined amid this tug-of-war. Doctors and hospitals say they’re patient-centered, and insurers say they’re member-centric — but the jargon is a dead giveaway. Each side is focused on their half of the pie, and neither is accountable for the whole person: the person receiving care and paying for care, not to mention navigating everything in between.

It should come as no surprise that trust is falling. Only 56% of Americans trust their health insurer to act in their best interest. Even trust in doctors — the good guys — has plummeted. In a startling reversal from just four years ago, a whopping 76% of people believe hospitals care more about revenue than patient care.

This trust deficit is the root cause of so many healthcare problems. It’s the reason people disengage, delay and skip care, and end up in the ER or OR for preventable issues. When a good chunk of the population falls into this cycle, as they have, you end up with the status quo: unrelenting costs and deteriorating outcomes that is dragging down households, businesses, and the industry itself.

There’s no quick fix. Despite what my fellow entrepreneurs might say, no one point solution or technology (no, not even AI) can rebuild trust. The only way to reverse the downward spiral is by serving up a modern experience that is genuinely designed around people’s needs.

Brace yourselves: Building that experience doesn’t require rebuilding the whole system. But it does require step change. It’s time for leaders and innovators across the ecosystem to reimagine and redefine partnerships, people-first care, and payment models to create a new center of gravity in healthcare, one that sits outside the traditional orbit of providers and insurers, yet is also connected to all the capabilities and expertise the system has to offer. That’s the fix, and here’s what I think that looks like:

People and purchasers, together

The group commercial insurance market may very well be healthcare’s new center of gravity. Think about it: collectively, the private employers and public-sector organizations that make up the market represent the nation’s largest purchasers of healthcare, providing health insurance to nearly 160 million Americans. Thanks to their scale and influence, these organizations are uniquely positioned to actually rise above the status quo and create an alternative to the provider-insurer dynamic.

Aside from scale, the interests and incentives of these plan sponsors are naturally aligned with those they cover. People (employees) and purchasers (employers) both want the same thing. Employees and their families want more healthy days, with lower premiums and out-of-pocket expenses. Employers want a healthy, happy, and productive workforce, while reducing their astronomical healthcare spend — projected to be up 9% for private employers this year. In contrast to the zero-sum game between providers and insurers, better health outcomes at lower cost are a win-win for people and purchasers.

Self-funded employers—which represent two-thirds of the group market, and skew larger—are especially important players, due to their purchasing power and their ability to curate benefits and services for their workforce that tap into the best capabilities the system has to offer. Rather than relying on a single carrier, many self-funded employers contract directly with leading brick-and-mortar health systems (as in the centers of excellence model), as well as best-in-class service providers across the healthcare ecosystem.

End-to-end integration (for real)

The historical divide between providers and insurers has fractured the healthcare experience, but that’s not the only culprit. In fact, the proliferation of point solutions, digital health apps, and third-party service providers has exacerbated many of the cracks and pain points in the system. “Front doors” that claim to streamline the healthcare experience for employees too often open onto the same fragmented and confusing landscape, if they lead anywhere at all. 

Repairing the experience has to start with integration, and not just clinical integration. Yes, integrated care matters. Connecting primary care with behavioral health and specialty care, blending virtual and in-person experiences, giving care teams shared access to the same data—these are all essential steps. But integration must go much further. Clinical quality and outcomes are inseparable from the administrative, financial, and logistical aspects of healthcare that have long been stranded between providers and insurers.

People intuitively understand the relationship between their mental, physical, and financial health, and they need a trustworthy support system that will address all of these dimensions together, through navigation, financial advocacy, social support, and other historically siloed services

A modern take on value-based care

Value-based care has long been viewed as a solution to the misaligned incentives the fee-for-service model has created among providers and insurers. Two decades of experiments led by Medicare, however, have had mixed (some would say disappointing) results. But those calling for an end to the value-based project are overlooking the untapped potential for alternative payment and care delivery models in the ever-important commercial market.

Healthcare value, as a concept and practice, is relatively new to the commercial space. Value-based arrangements between health plan sponsors and their healthcare partners have largely been limited to pay-for-performance models and bundled payments for specific clinical services (as with centers of excellence). While some of these targeted solutions do provide savings, measuring ROI has been more of an art than a science. Specifically, the lack of integration described above — integration spanning multiple service providers, as well as clinical and non-clinical services — has made it difficult for plan sponsors to attribute improved outcomes or cost savings to specific solutions.

New value-based partnership models are changing that. Though value-based contracts can take many forms, the leading edge in the commercial market is a shared savings model that incentivizes healthcare service providers and insurers to join forces and drive outcomes that matter to people and purchasers, including experience, clinical quality, and — most important — the total cost of care. It’s not enough to have the right partners and capabilities in place. The model needs to ensure alignment and accountability.

Conclusion: From downward spiral to flywheel

When these pieces come together in a healthcare experience that earns people’s trust, the spiral of high costs and poor outcomes starts to reverse itself. An easier and more integrated people-first experience drives engagement, which improves outcomes. Better experiences and outcomes build trust, which drives further engagement, and so on. Eventually a flywheel effect kicks in: As people get healthier, they need less high-cost care, and they’re more resilient and productive — and that value is passed on to the purchaser.

Healthcare isn’t broken. We don’t need to dismantle or overhaul the system. We just need to get in a better formation so that the very best of the system actually works for people, not against them.

Owen Tripp is the co-founder and CEO of Included Health, a personalized all-in-one healthcare company that partners with employers and public-sector organizations on value-based care.