elevancehealth.com

Commercial Population

Contributing experts: Morgan Kendrick and Razia Hashmi, MD

The words "Commercial business" represent the array of health plans that our affiliated health plans offer. Commercial health plans serve a range of customers — from individuals buying subsidized insurance on Affordable Care Act marketplaces to large, multinational, self-insured employers, and everything in between.

Employers have a long history as the dominant purchaser of health insurance in the U.S, covering about half of all Americans.1 Generous healthcare coverage is a sought-after benefit for employees — and a differentiator that most employers want to provide as part of their strategy to attract and retain top talent.

At the same time, the cost of healthcare continues to rise, and employees are interested in broad access to care providers, as well as innovative offerings to meet their changing needs. The average cost that U.S. employers pay for their employees' healthcare is expected to rise by 6.5% in 2023 to $13,800 per employee,2 putting pressure on companies that are working to balance their financial reality with their employees' expectations.

The good news: It's possible to offer quality, affordable healthcare that meets the needs of employers and their employees. Rewarding value over volume and designing networks that offer choice will position our healthcare system to deliver coverage that leads to better outcomes at lower costs.

Average cost U.S. employers pay for employees' healthcare expected to rise by 6.5% in 2023 to $13,800 per employee

Our Approach: Shifting to Value

At Elevance Health, our Commercial health plan affiliates serve more than 31 million Americans.3 With national scale and local density, we are uniquely positioned to advance the "shift to value" on behalf of employers by helping care providers of all types participate and perform well in value-based care arrangements.

Our Commercial value-based solutions span the care continuum from primary care to specialty care to hospital and ancillary services, such as post-acute care. We do not take a one-size-fits-all approach. Our solutions are tailored to meet care providers where they are, so they can enter into value-based arrangements and move along the risk-sharing spectrum as they demonstrate improved outcomes.

Partnering across the country, we are driving measurable improvements in affordability and quality of care for our Commercial population through a variety of solutions for primary care providers and specialists. There are approximately 100,000 care providers and 200 accountable care organizations participating in these value-based payment arrangements.4

Among those solutions are:

Enhanced Personal Health Care (EPHC)

Our flagship value-based solution aims to improve quality outcomes and control cost-of-care trends in local markets. Care providers in EPHC are incentivized for delivering quality, efficient care by focusing on prevention and wellness, offering personalized plans, and coordinating treatment across the spectrum of care.

Oncology Medical Home Plus (OMH+)

This solution supports medical oncologists in the shift from volume to value by holding them responsible for consumers undergoing active chemotherapy treatment. Oncologists are incentivized to align treatment with patient goals, follow evidence-based care plans, reduce cost of care through comprehensive management of chemotherapy regimens, and support patients through transitions of care and various modalities.

We support care providers by offering digital resources, population health analytics, and practice transformation tools for improved decision-making. OMH+ care provider partners are encouraged to improve patient outcomes through value-based cancer care pathways rooted in evidence-based medicine, lower cost of care through appropriate use of services, and improve consumer satisfaction through better coordinated cancer care and avoidance of emergent care.

Episode-based payments

These "bundled" payments encourage cost-effective coordination between primary care, specialty care, and ancillary health services by holding specialists accountable for cost and quality outcomes for a consumer's entire episode of care. This payment model combines payment for the full continuum of care surrounding a procedure. This drives down care fragmentation and supports improved outcomes for high-volume, high-cost specialty care, such as pregnancy, joint replacement, and colonoscopy.

Specialists across women's health, gastroenterology, cardiovascular care, and musculoskeletal care are held accountable for improving quality and driving affordability. Further, improved collaboration between primary and specialty care providers enhances the consumer experience.

When it comes to meeting the needs of those looking for Commercial products, including employers with employees in multiple states, national scale and local relationships matter. Our goal is to collaborate with care providers, bringing together our population health capabilities, analytic insights, artificial intelligence, and clinical "wraparound" strategies to complement their patient-specific actions. These efforts help reduce care provider administrative burdens for things like utilization and care management, while tackling medical costs and improving consumer health.

Our Progress

We're seeing meaningful progress when comparing critical health indicators among our Commercial consumers in value-based arrangements to those who are not. For example:5

Enhanced Personal Health Care vs. Non-Value-Based Care

Breast Cancer Screenings: 5.6%

Diabetes HbA1c Testing: 4%

Childhood Immunization Status MMR: 3.3%

Pediatric Well Care Visits (Ages 3-6): 2.9%

Pediatric Well Care Visits (Ages 12-21): 5.6%

These results, analyzed in depth in Health Affairs, demonstrate the promise and potential of value-based care to impact not only the health of populations but also its cost.

Spotlight: Center of Excellence

Over decades, healthcare has evolved into an industry of hyper-specialization. With the proliferation of medical subspecialties — each requiring intensive training — each care provider or healthcare system simply cannot be expected to be exceptional at every procedure. Yet employers, especially those with self-funded health plans, reasonably expect their health plan to guide employees to quality, lower-cost care.

Given our national scale and local relationships, Elevance Health has a unique vantage point and the ability to do just that.

One such example relates to heart valve procedures, an area where one facility designated by our health plan affiliates as a Center of Excellence stands out. Our data shows that the Center of Excellence excels in terms of:

  • Cost — with costs per admission among the lowest in the nation and far lower than other hospitals.
  • Quality — with performance measures like 90-day readmissions being about half of the national average.

Valve Procedures Example: Cost Per Admission ($K)

Lower Performing: California: 182, New York: 218, Academic Peer A: 280, Academic Peer B: 288

Medium/Lower Performing: Colorado: 158, Georgia: 157, Maine: 150, Virginia: 161

Medium/Higher Performing: Connecticut: 137, Indiana: 128, Ohio: 131, Wisconsin: 134

Higher Performing:, Kentucky: 89, Missouri: 111, New Hampshire: 108, Nevada: 114, Center of Excellence: 119

With access to robust national data, we can guide consumers toward care providers who are particularly effective in terms of care delivery and affordability, as well as those who emphasize important considerations of health equity and patient experience.

Forward Together

The impacts of COVID-19 on workforce norms, the "great resignation," and other macroeconomic factors continue to complicate employer efforts to balance attracting and retaining talent, while attempting to control rising healthcare costs. We will continue to innovate across our market-leading portfolio of Commercial solutions and meet the demands of our clients by:

  • Empowering primary care providers, especially those in independent practices who need more support.
  • Guiding employees to high-performing care providers who excel at delivering quality, affordable care.
  • Facilitating whole health, with an intentional focus on social factors and advancing health equity.
  • Delivering personalized experiences through digital innovation and virtual care.
  • Utilizing the industry's largest dataset to ensure analytic insights are driving our strategy.

As our employer clients seek solutions that drive real value for their employees — cost efficiency without compromised quality — we will continue to embrace value-based care at every step along the healthcare continuum.

1 Kaiser Family Foundation, Health Insurance Coverage of the Total Population: 2021 (Accessed December 2022): kff.org. 2 SHRM (the Society for Human Resource Management), Medical Plan Costs Expected to See Bigger Rise in 2023 (August 16, 2022): shrm.org. 3 Internal data (2022). 4 Internal data (2022). 5 Internal analysis (2022).