Are your members getting the care they need? Seven questions will help you find out.

A Look at Statistics

• 90% of U.S. annual healthcare costs ($4.9 trillion in 2023) is spent on treating chronic disease and mental health conditions.
• Of the top 10 leading causes of death in the US, half are related to preventable and treatable chronic diseases. Cardiovascular disease, cancer, and diabetes are the top 3 causes of death.
• Breast cancer accrued the highest treatment cost of any cancer—$29.8 billion in total medical costs in 2020. However, on an individual level, after an average cost of $35,000 for the first year after diagnosis, continuing care was just a tenth of that cost.

The answer to reducing member and employer healthcare costs seems straightforward: simply provide preventive and primary care. But it’s not that easy, and the biggest reason is that it’s still too difficult for members to find and use the care they need.

Member Care Checklist

Here are seven questions — along with guidance on answering them — that will help reveal barriers in your plan that may be driving avoidable costs and worsening health outcomes.

1. Is primary care readily available to members?

• Consult the University of Wisconsin’s County Health Rankings & Roadmaps to see how many primary care physicians are in counties where many of your employees live. Many counties have significantly fewer physicians than the U.S. average (1 primary care physician per 1,330 people).
• Determine how many primary care providers in your network are accepting new patients, then conduct a spot check to see how long it takes to schedule an appointment for an annual physical and if same or next day visits are available for acute needs when employees are sick.

2. Are members getting the primary and preventive care they need?

• Review claims data to see how many members are up to date with wellness exams, immunizations, and screenings.
• Compare your ratios to benchmarks of similar populations, keeping in mind current benchmarks leave a lot of room for improvement.

3. Are members using alternatives to primary care?

• Are there many emergency room visits for non-emergent conditions?
• Is there above-average use of urgent care and retail clinics?

4. Are chronic conditions under control?

• Look for signs that members are not getting treated for diabetes, asthma, hypertension, and the like. Example: increases in hospital admissions for diabetes-related kidney and heart problems.
• Analyze claims to see how many members with chronic conditions are receiving recommended treatments.

5. Can members get the mental health care they need?

• Review the availability of mental health care providers in your network and the wait time for an initial appointment.

6. Does your plan design discourage preventive care or follow-up treatment?

• One example: Members with some high-deductible health plans are wary of seeking preventive care, even when their plan covers 100% of it. They fear that if covered tests discover any issues, they will face hefty bills for additional diagnostic tests and treatments.

7. Do members find accessing care to be a challenge?

• Some may live in “health care deserts,” where there are few providers available.
• Others may have issues because they can’t travel, lack childcare, or don’t speak English.

Next Steps

With the answers to these questions in hand, you can make it easier for members to get care by designing a strategy that includes actions such as:

• Expand your network in certain areas or specialties (e.g., mental health).
• Support direct primary care providers that offer increased patient access in return for a monthly fee. With new direct primary care marketplaces gaining traction in the U.S.—digitally aggregating disparate providers—options are available to any employer.
• Expand access to telehealth services.
• Encourage health screenings through communications programs and incentives.
• Implement care management programs for chronic conditions.
• Adjust high-deductible health plans to ease expenses that follow preventive screenings.
• Engage care navigation services to help members find suitable providers. Using quality and cost data to support navigation and steerage could save up to 12-15% PEPY according to some reports.
• Create on-site or near-site medical facilities. It has been reported by PBGH and others, that good primary care lowers health care costs by as much as 33%. In fact, in a study Alliant performed across 25,897 claimants, employer-sponsored primary care clinic users cost $1,029 PEPY less than non-clinic users in medical claims alone.

For more insight into these and other approaches to expanding access to preventive and primary care, see our recent articles on expanding access to primary care and the barriers to preventive care.

How Alliant Can Help

Alliant has worked with employers nationwide to understand and respond to their members' health care needs. Our sophisticated tools can analyze claims data to identify access issues. We can also assist in strategy, selecting vendors, and designing plans to address any issues. With our extensive experience and expertise, we are happy to help you set up on-site, near-site, or direct primary care health programs as well. Learn more about our employee benefits services and solutions.