医疗保健融资的未来：可持续模式的路径

Pathways to sustainable models Contents Introduction3Challenges in health care financing4Solutions for a new era of financing6Mobilizing for a transformative future in health care financing10Transitioning to the future of health care financing11Get in touch12 Introduction While health care has evolved and grown as a significant portion of the economyin the United States over the past century, the landscape of health care financinghas remained remarkably static and consistent. As the medical field continuesits rapid evolution and new scientific breakthroughs in care come to market,the current financial models are increasingly at odds with the promise of theseimprovements in patient longevity and quality of life. This misalignment has thepotential to create obstacles to access, stifle further innovation and, ultimately,affect patient health outcomes. “Insurance” by definition is meant to protectagainst the risk of unforeseen accidents but has evolved in health care to be acatch-all funding mechanism for every health-related need. We have identified several key challenges and potential solutionsto realign health care financing with the evolving landscape ofhealth care needs. Challenges in health care financing Some of the major challenges in financing health care today involve the timing, predictability,and magnitude of costs—and the knowledge gap between choice and cost: 1.Timing of funding and cost 2. Predictability of costs Health care costs and the benefits they deliver oftenspan multiple years, yet current health insurancemodels assess risk and set premiums on an annualbasis. This can create misalignment between theduration of funding and the long-term value of healthcare interventions. Insurance is a financing mechanism to plan for the risk ofunpredictable events (see sidebar,Rethinking ‘insurance’:A conceptual mindset shift). However, for healthinsurance, many health care costs are predictable based onhistorical data, leading to complicated financing models tomanage the mix of predictable and unpredictable costs. Key challenges: Key challenges: •Known costs and premiums.The costs of chronicconditions, routine care, and preventive services arelargely predictable. Additionally, recent claims datacan provide predictability into major costs expectedto continue into the following year. This can result inhealth insurance premiums being heavily weighted onknown costs creating a model that is focused on coveringpredictable costs for the following year versus trulycovering unpredictable risks. •Annual pricing and risk assessment.Theyearly nature of health insurance risk assessmentsand pricing doesn’t necessarily align with long-term positive impacts from active chronic caremanagement and disease prevention. •Legacy expectations and consumer behavior.The established expectation that health insurancecan generally be changed annually can encourageconsumer behavior that leads to high churn rates. Thiscan destabilize coverage continuity and complicatecost management, and risk pooling compared tolonger-duration life and disability insurances, whichtend to promote stability and predictability. •Anti-selection.Consumers have insight into their knownconditions and are likely to select better coverage for theirpersonal needs. As consumers pick plans with bettercoverage for their known conditions or medications,insurers may pick up a disproportionate portion ofpatients with a specific condition without knowing about it. 4.The knowledge gap betweenchoice and cost 3.Magnitude of costs The United States tends to be a leader in health careinnovation, continually pushing the scientific boundariesof medical technology and treatments. There arenumerous factors that drive different cost structure forinnovative technologies and treatments in the UnitedStates compared to other countries. Given the complexity of the current health care ecosystem,consumers may have misunderstandings about howto navigate their health as well as the long-term costimplications of their health decisions. This can createchallenges with informed decision-making that balancescosts and health care impacts. Solving this will likely requireenhanced public education, improved health literacy, anda restructuring of financial models to balance health caredecisioning and the associated cost implications. Key challenges: •High-cost innovations.Advanced treatments likecell and gene therapy (CGT) are highly personalizedand potentially curative but at very high costs for avery small population.1These expenses are spreadacross all insurance policyholders, resulting inhigher overall premiums to compensate for the rareinstance that one of these therapies is needed for theindividual patient. Key challenges: •Education and decision-making.Growth in high-deductible plans can provide consumers with somevisibility into short-term costs for specific services;however, consumers often lack important informationabout the long-term costs and outcomes associ