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Health Plan Strategies for Value-Based Care: Closing Gaps in Care Means Getting Serious About Prevention

The American Journal of Accountable Care®December 2018
Volume 6
Issue 4

Preventive services are severely underutilized and contribute substantially to care gaps and preventable deaths. Three key trends promise improvement: consumerism, big data, and technology.

The American Journal of Accountable Care. 2018;6(4):26-27Three key movements—consumerism, big data, and technology—are transforming the landscape of value-based care. Nowhere is this transformation more evident, or more needed, than in the delivery of high-value clinical preventive services, which often go undelivered in today’s health system, resulting in gaps in care.

Preventive service delivery is ripe for disruption. To date, the healthcare industry has focused almost exclusively on the treatment of illness, often to the neglect of prevention. Meanwhile, the number of quality measures and clinical guidelines related to prevention has continued to grow. Clinical preventive services are generally low-risk, are appropriate for large numbers of people (ie, high volume), are guideline-driven, and support fundamental value-based care objectives. Despite this, preventive services are underutilized at alarming rates, contributing substantially to the overall number of care gaps and preventable deaths in any given population.

Bucket 1: Traditional Clinical Prevention. Increase the use of evidence-based services.

Bucket 2: Innovative Clinical Prevention. Provide services outside of the clinical setting.

Bucket 3: Total Population or Community-Wide Prevention. Implement interventions that reach whole populations.

The CDC’s John Auerbach called attention to the need for innovative delivery of preventive services in his seminal 2016 article, “The 3 Buckets of Prevention.”1 Auerbach offers 3 areas of preventive care as fundamental to improving population health:

Auerbach’s second bucket of prevention, in which high-value services are liberated from traditional clinical settings in order to increase desirable utilization, is particularly relevant to health plans pursuing value-based care objectives. Historically, healthcare providers have lacked the tools to expand delivery of preventive services beyond the walls of their own clinic on a meaningful scale. Modest reimbursements, among other factors, have limited investment in potential solutions. As pressure mounts to meet quality measures and improve outcomes, health plans are bridging the gap between the doctor’s office and the places where health is actually generated: at home and in the community. Here are some of the ways leading health plans are embracing consumerism, big data, and emerging technologies to transform utilization of high-value preventive services.

Answering the Call for Convenience

Convenience is key to driving utilization of preventive services. Expanding care delivery to include nontraditional settings, thereby increasing convenience, is central to Auerbach’s second bucket of prevention. To meet this end, many health plans are turning to cost-effective delivery options in members’ homes. These offerings include low-cost testing, health needs assessments, and care delivery, depending on the acuity of health needs in the population. Convenient retail outlets have long partnered with health plans to deliver pharmacy services, but today’s retail pharmacies are investing in the ability to provide a litany of additional services, expanding the experience of care in a setting that members already frequent. Even the workplace, long treated as the domain of the worksite wellness industry, can be a valuable care setting to reach members where they already are. Health plans are increasingly working with partners to affect care across a variety of nontraditional settings.

Making the Most of Big Data

Most health plans use large data sets to determine the members of a population who are eligible for a given service. Some plans are beginning to use big data to evaluate who will participate in a service, how to maximize the likelihood of participation, who will benefit most from that service, and what the ultimate clinical and financial impact of that utilization will be. Data on consumer behavior and social determinants of health are an important addition to the traditional melding of prescription, laboratory, and other clinical data points with claims. As the number of ways to deliver high-value service increases, more and more emphasis will be placed on evaluating the success of novel interventions so that plans can invest in what is working and abandon what is not.

Activating Members via Simple, Scalable Technology Solutions

To date, gap closure programs have focused on member engagement efforts predicated on personalized marketing and communication to appeal to healthcare consumers. In the Harvard Business Review article “Know Your Customers’ ‘Jobs to Be Done,’ ”2 Christianson et al encourage organizations to view these personalized efforts through a new lens that emphasizes knowledge of a member’s challenges over knowledge of the member’s characteristics. The authors suggest that whenever a consumer purchases a product or service, they are essentially “hiring it to get a job done.” This approach favors solutions that focus on helping a member consume preventive care—completing a job they need to do—rather than convincing them to do so. It requires health plans to understand their members as people and consumers and to create a member experience that marries engagement tools with novel delivery solutions that can help members get those jobs done.

Health plans should also consider the jobs that providers need to get done and how technology can help. Providers are not opposed to the delivery of clinical preventive services; they view these services as an important part of their job. Gaps in delivery occur because providers are inundated with competing priorities and have few technologies available that are purpose-built for getting the jobs of prevention done. Investment is needed in integrations that allow providers to access alternative settings of care and novel delivery solutions, and, in turn, connect back to their usual workflow. Payers are increasingly part of the solution for getting these jobs done.


Preventive service strategies that encompass convenient, data-driven engagement beyond traditional care settings can have a profound effect on population health. By embracing consumerism, big data, and task-oriented technology platforms, health plans can drive care gap closure and achieve Quadruple Aim goals to positively impact health, decrease the cost of achieving that impact, and improve the experience of both members and clinicians along the way.Author Affiliation: BioIQ, San Francisco, CA.

Source of Funding: No external funding.

Author Disclosures: Dr Sclar is employed by BioIQ, which provides healthcare services in home and retail settings.

Authorship Information: Concept and design, drafting of the manuscript, critical revision of the manuscript for important intellectual content, and supervision.

Send Correspondence to: Joshua Sclar, MD, MPH, BioIQ, 2300 Windy Ridge Parkway, Suite 850 South, Atlanta, GA 30339. Email: jsclar@bioiq.com.REFERENCES

1. Auerbach J. The 3 buckets of prevention. J Public Health Manag Pract. 2016;22(3):215-218. doi: 10.1097/PHH.0000000000000381.

2. Christensen CM, Hall T, Dillon K, Duncan DS. Know your customers’ “jobs to be done.” Harvard Business Review. September 2016. hbr.org/2016/09/know-your-customers-jobs-to-be-done. Accessed July 10, 2018.

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