How Highmark Inc. is Simplifying Insurance Benefits to Improve Care

older black man eating breakfast while reading his health insurance benefits handbook

Millions of people sign up for health insurance plans each year through an employer, via Medicare or Medicaid, or on the ACA health exchange. And many struggle with understanding exactly what’s in their plan and how much it will cost to get the care they need. If you’re one of those people, you’re not alone.

Health insurance plays an integral part in our lives, but few people have a good understanding of their plans and benefits. Insurance carriers can help change that, says Highmark customer experience expert Anna Roberts.

“My team’s job is to help Highmark imagine what it's like for people to buy insurance and then get the care they need,” she says.

Why is choosing health insurance so confusing?

There are many different players within the health care and insurance system. It’s a complicated industry that often leaves people with more questions than answers. Health care is also a necessity for most people, so most can’t opt out.

Health insurance differs from other insurance products

For starters, health insurance works on a completely different model than other common insurance products we use. Many adults also have auto insurance and homeowner’s or renter’s insurance policy. It's natural for them to assume that health insurance plans will be similar. Unfortunately, that's not the case.

For example, once you pay the deductible for an auto insurance policy, the plan covers all the costs up to your plan maximum. With health insurance, meeting the deductible usually means you will owe coinsurance (a portion of the payment toward health care services) until you reach your out-of-pocket maximum. You may also have multiple deductibles — for example, one deductible for the policyholder and a higher deductible for a spouse or other family members.

Health care coverage often includes complex language and unfamiliar concepts

Another challenge is the complex language and concepts required to understand insurance. Some of that language is mandated by the government, but not always. Sometimes insurance carriers assume people understand their benefits.

But according to the Center for Healthcare Strategies, more than 1 in 3 (36%) adults has some difficulty understanding health and care information. The American Medical Association (AMA) recommends that all information presented to patients be written on a sixth-grade level of comprehension. However, an analysis of insurance information shared with members revealedthat most communications are actually written at a high school or college reading level.

The rules can change often

Most people make health care decisions based on a doctor’s recommendations and past experience. But insurance can make that harder in two ways:

  • Physicians and care teams provide care based on their clinical knowledge and expertise. They may not know what is covered by specific insurance plans — or which facilities and providers are in a patient’s insurance network.
  • A person’s past experience isn’t always a good indicator of future care. For example, if you got a mammogram at a certain care facility last year and it was covered 100% by your insurance, you are likely to go to the same facility again. But if you changed insurance, that facility may be out of network, and the new plan may only pay 50% of your costs.

Insurance carriers often assume people will check these details before they get care, but not everyone does. That creates frustration and confusion when services are not covered or costmore than expected after a change has occurred.

The potentially high stakes of selecting an insurance plan

Another complicating factor in selecting and using health insurance benefits is the inherent risk. Choosing a plan feels like a very important decision, but there are many unknowns that caninfluence whether you make the right choice.

Unfortunately, it can be difficult to know how to weigh those risks and select the plan that provides the best coverage at the lowest prices. Getting it wrong could mean large out-of- pocket expenses, which create a challenge for most households.

“As many as 40% of people in the U.S. don’t have enough money in the bank to cover an unexpected bill of $400 or more,” says Roberts. They also don’t have extra monthly income to put into high-deductible health plans or health savings accounts.

The Department of Health and Human Services recently reported that 1 in 5 Americans has experienced surprise medical billing. Average bills range from $750 to $2,600 or more per care episode. Selecting the wrong plan could result in surprise bills or costs that health care consumers can’t afford to pay. In a 2020 survey, 22% of respondents said they skipped out onmedical care because of the expense.

Addressing the short-term and long-term challenges

In the short term, simplifying benefits and making them easier for people to understand can translate to better health because people get the care they need. But Highmark Inc. has their sights set on even more long-term benefits. Highmark is working toward a health care experience that:

  • Lowers total cost of care as people and providers prioritize preventive care.
  • Provides better chronic care management to slow disease progression and reduce the need for emergency room visits or hospital admissions.
  • Offers a more comprehensive and holistic view of people that considers barriers that might prevent someone from getting care.
  • Focuses on social determinants of health (factors outside of the care experience that influence overall well-being), such as food insecurity or transportation challenges.

“A lot of our ability to improve health is centered around preventive care and chronic care management,” says Roberts. “We want to make sure people get the care that helps them stay healthy instead of just ‘sick care.’”

To do that, Highmark Inc. is investing in resources centered around how insurance can facilitate health and wellness. They are examining the current mental models people have and their motivations for getting (or skipping) care. With that information, they can build insurance plans that match up with how people access and pay for care in the real world.

The necessary changes to the insurance experience won’t come overnight. But Highmark Inc. iscommitted to exploring every aspect from a member’s point of view. Those insights can point to specific care goals and potential barriers that might keep someone from achieving those goals. Then Highmark Inc. can work on solutions to remove those barriers.

Taking a unique approach

Before coming to Highmark Inc., Roberts worked with game designers. Insurance and game design might not seem like a natural fit, but the concepts are actually very similar. “Game designers make super complex experiences easier to navigate, either in the educational or entertainment spaces,” she says. They spend time thinking about the mental models required to get through a process, and what motivates someone to play a specific game.

Applying game design concepts to the insurance world means discovering what motivates people about their health and what they understand about how health care works. The Highmark customer experience team is using this research to develop a centralized research library. By creating custom roadmaps, they can better align people's experiences with their health care — all while finding and fixing gaps along the way. When we succeed, we make a complex system simpler for patients and providers alike.

Ultimately, what used to be very complex becomes easier, and everyone in the health careworld can understand and work together. And that’s the ultimate goal for Highmark, Inc.