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Can health insurers fix our broken health care system?




Can health insurers fix our broken health care system?

The man wants to show Pat his pills.

He is 77 years old and has trouble walking, so he asks his seven-year-old grandson to get his medicine from a plastic container he keeps in the bathroom. The boy returns with a pill bottle. “No, the white one,” the man says to the boy.

“But Pappy,” the boy says. “They are all white.”

Pat has seen this before.

She asks the boy to bring out the entire bath. In the man’s living room, she searches through the bottles, carefully making a list of the various medications and noting which bottles are duplicates or have expired. “Now that I know what you’re taking,” she says to the man, “we can get started.”

Pat Salas is not a pharmacist. She is not a licensed physician, health care navigator, or community health worker. And yet Pat is responsible for ensuring that hundreds of people get the care they need.

Pat Salas is an insurance broker, one of thousands across the country whose work is essential to promoting positive health outcomes. In my experience, I have found that real estate agents are often trusted members of their communities. Should we rely more heavily on it to bridge the gaps in care that plague our healthcare system?

Looking for better results

By 2023, beneficiaries had an average choice of 43 different Medicare Advantage plans. Choosing the right one can be a challenge. New research commissioned by SCAN, the diversified health care organization I lead, shows that about half of Medicare beneficiaries have spoken with a broker to understand their coverage options.

“My goal is to help people achieve better outcomes and live better lives,” says Salas, owner of South Bay Healthcare Insurance Services in Chula Vista, California. Regulations prohibit Salas and other brokers from asking direct questions about the health of potential clients to ensure that the insurers they represent cannot cherry-pick members, that is, only accept members without complex terms and conditions. Still, Salas says, when she meets potential clients, “most people have very little problem sharing their health concerns.”

Salas usually steers conversations toward the client’s medications. Her first priority is finding a plan that gives them access to those medications at a low cost. She then looks for plans that offer access to physician groups that can help the person with their condition. Finally, she looks at other benefits of the plan, such as over-the-counter drug programs, transportation options and gym memberships. “This is what we should all be doing,” she says.

Outside registration

Once a plan is selected and the client is enrolled, says Maggie Stedt, a broker who served as president of California Health Insurance Underwriters, brokers have a responsibility to follow up and ensure their clients have access to care. Stedt says she regularly helps clients who need help connecting with their doctors or navigating hospital bureaucracies. “We facilitate how we can use care and where we can go for it,” she says. “A good agent learns over the years which paths to take.”

Terry Huber, owner of Pure Benefits, an insurance company in Albuquerque, New Mexico, opened a space in her Albuquerque store specifically to give customers access to care and other services. Inside, employees guide customers to local optometrists and audiologists whose services are covered by their plans. She has also held member meetings with pharmacists, explaining where people can find the best discounts on generic and brand-name drugs, and conducts workshops on topics such as living wills and end-of-life planning. When a client asked where she could be buried cheaply, Huber found a cemetery on the mesa where people could be buried without a casket.

“We want to be trusted advisors for people in a place where they can get good information and help,” Huber says.

Sometimes customer requests are much more direct. Salas employs three social workers to meet the needs of her clients. When clients do not have access to food or are evicted, they refer them to social service organizations that can help them.

In some cases they provide the help themselves. They often buy groceries for food insecure customers. Salas once bought an incontinent woman $1,000 worth of adult diapers. The woman’s health plan promised to send them, but Salas knew it would take weeks for them to arrive, and in the meantime she was unwilling to see her client suffer the shame of walking around with dirty clothes.

“None of this is necessarily related to their plan,” Salas said. “It’s not part of being in the agency and it’s not a requirement; it is a basic service that we provide because it is human.”

Formalizing the relationship

Based on my conversations with brokers and other healthcare professionals, the work Huber and Salas do outside of plan selection is not atypical. Yet it falls outside their job description.

But should it be so?

For years, healthcare experts have argued that with physician shortages and rising costs, we need to expand care beyond the walls of hospitals and medical offices, into the communities where our patients live. With that in mind, I would say it is time to officially evolve the role of the healthcare broker into one where they:

  • Help people navigate the healthcare system, with an emphasis on connecting them to preventive medical care
  • Stand up for people who struggle to access needed services and benefits
  • Promote healthy habits and behavior changes that can eliminate the need for expensive medical care
  • Access community and other public resources that can improve health outcomes

If this sounds like the work of community health workers, it should. However, there is often a shortage of CHWs, and there is no reason why they should have a monopoly on providing these types of essential services, especially when brokers have often already earned the trust of the people they serve and have the skills to motivate behavioral change.

Adjustment of the current payment model

Some people will say that I am both exaggerating the importance of brokers and making an argument for increasing their fee structure. That is not the case either. For starters, I’m aware that many brokers see their work in purely transactional terms: they sign the client up for a plan, collect their commission, and disappear until the following year’s enrollment period. But I also think the days are numbered for these types of brokers: given the ease of comparing plans and signing up on the Internet, I believe consumers want more from brokers than just a friendly face and some efficiency with paperwork.

Second, almost all real estate agents I meet say they are already well compensated, and I don’t believe we should pay real estate agents more to bring better health to their communities; we have to change. (First, many brokers are already doing this.) More importantly, the structure by which brokers are currently paid already creates the financial model that can incentivize them to make providing community health services an integral part of their work. Brokers of Medicare Advantage plans receive an “Initial Year” reimbursement from health plans when they enroll a new member (CMS recently proposed increasing payments to $726 in most states and to $880 in some). Crucially, they receive a significant “renewal payment” when the member signs up each subsequent year (CMS recently proposed increasing payments to $363 in most states and up to $440 in some). These renewal fees must be earned; and the way they should be earned is by annually providing clients with care navigation and other health care services that produce positive clinical outcomes. I believe that agents who do not offer such services should receive lower renewal fees – or perhaps no longer serve seniors.

I note that the Centers for Medicare and Medicaid Services (CMS) recently released new rules about broker payments. These rules have led to numerous lawsuits. If the changes take hold, individual brokers will see higher payments for new registrations and renewals, which will provide additional incentive for them to formally promote health in their communities. CMS can improve health and meaningfully expand the health care workforce by aligning broker payments with health promotion work; the potential improvements in health outcomes could be transformative for the U.S. healthcare system.

In short, it’s time to codify and standardize the work of healthcare brokers to ensure that the services people like Pat Salas, Terry Huber, and Maggie Stedt provide are not “nice-to-have benefits,” but rather standard offerings that you can expect from everyone. broker. As these three women prove, healthcare brokers are trusted and informed members of the community – exactly what we need more of to improve the health of our members. It is time to redefine our relationship with them and tap into their power to bring healing to our members.