HEALTH| 15.09.2021

New models for health care services: finding better and more sustainable ways to provide health benefits

Juan Francés

We are living in times of rapid economic and social change, and the new developments taking place in relation to health care are no exception.

The prevalence and impact of complex chronic illnesses, such as cardiovascular disease, cancer, diabetes, and mental health disorders, are on the rise. Patients suffering from illnesses such as these may require health care services over the course of several decades.

At the same time, despite the increasing incidence of many types of illness, people are living longer. The WHO has estimated that in the year 2050, there will be 2 billion people worldwide over 60 years of age, which is more than double the figure recorded in 2015, and there are already more people in that age group than children under the age of five.

These demographic trends have profound economic implications for our society. In all parts of the world, the majority of medical care budgets are now dedicated to complex, chronic medical conditions associated with advancing age. However, the provision of health care and social services remains concentrated in hospitals and specialized settings, which represents an inefficient use of limited health care resources.

The result is a decrease in the quality of care received by patients, while at the same time costs are increasing in an uncontrolled manner. This is because the complexity of the demand is not being addressed by the “traditional” models applied to health care services.

How can we absorb the rising costs of health care for aging populations without endangering the sustainability of public funding or the life insurance and health insurance industry?

This is the question addressed in the recent study by Adrita Bhattacharya-Craven and Nicholas Goodwin, published by the Geneva Association and entitled New Care Models. How insurers can rise to the challenge of older and sicker societies.

That research brief, produced by the think tank created by some of the leading international insurance companies, including MAPFRE, is focused on the New Care Models (NCMs) that have begun to emerge in recent years.

As explained in the study, these NCMs represent a new approach to providing health care with a “triple aim”: to improve care experiences and health outcomes and encourage more cost‑effective service delivery.

These new care models have a series of characteristics in common: firstly, they emphasize prevention over treatment, with the goal of helping people mitigate the factors that contribute to the appearance of illness. Secondly, they integrate all aspects of health care needs, including those strictly related to health and those related to age and aging.

Thirdly, they try to “de-institutionalize” health care. This involves a reorientation away from costly hospitals and medical facilities and towards home-based and community-based alternatives, sometimes with the help of digital advances.

Measures such as these could result in significant improvements to the care experience and health‑related outcomes for patients while providing services that are less expensive for all parties involved.

Alfredo Castelo, MAPFRE’s Corporate Manager for Business and Clients, thinks that these new care models should be focused on “the need for a 360-degree perspective, where all stakeholders should be aligned, as closely as possible, with a new form of connected global health within a health ecosystem. The key starting point is to ensure that in this comprehensive perspective, the customers and their well‑being remain at the center of all strategies.”

In this context, there is a need for public-private collaboration in a manner that will allow insurance companies to offer services in coordination with government entities and address their specific needs in the context of the varying maturity of public health systems. Another element that can be incorporated into this type of public-private cooperation, and into a more global industry as well, is the critical role played by the cost of medications and, in turn, by pharmaceutical manufacturers. “We have seen the most international expression of this with the COVID‑19 vaccines, and it would be desirable to extrapolate this to other medical needs as well,” Castelo explains.

MAPFRE in the Dominican Republic as an example

The study published by the Geneva Association expressly cites the Dominican Republic’s model for public-private collaboration as an example, where private insurance companies are working together with the country’s national health insurance system. The Dominican Republic has a mandatory health insurance plan known as Family Health Insurance (SFS in Spanish). This plan covers all employees in the public and private sectors, retirees, and their families. SFS pays a per‑capita amount to independent health risk managers (ARS in Spanish), which are public and private entities and insurance companies that manage the national plan on behalf of the government. MAPFRE is included among those companies, through its MAPFRE Salud ARS brand, and it oversees general risk management and provision of services with a focus on comprehensive medical care.

With this approach, the insurance company associations found in each country play their part by standardizing the criteria applied by the companies, so that they will be providing consistent, coordinated, and agreed‑upon responses to the set of health‑related problems facing each society. According to Castelo, who coordinates a team providing services to 21 countries where MAPFRE operates in the health insurance line of business, “when taking on responsibilities in the role of health managers, insurance companies must be able to integrate efficient automated processes. They must also work together with the insured parties to coordinate their health care needs, as a way of improving the customer experience.”

The role of technology

Another challenge faced by insurance companies is the need to transform health insurance into health and well‑being insurance in the future. This must be done by bringing together basic trends such as a focus on well‑being, providing customers with devices that help measure their state of health, “the connected patient” concept, and the use of big data.

“The evolution of insurance from illness treatment towards illness prevention is a strategic focus. Technology will allow us to shorten diagnosis times. However, this must be done efficiently so that it does not lead to higher costs from the use of new technologies, and this is one of the challenges we face,” Castelo adds.

Private sector companies represent another significant stakeholder. Employers play a key role in the health care ecosystem because the health insurance they provide in the form of employee benefits has a significant social and business-related impact. “Companies are important social agents that facilitate access to health insurance and prevention programs, and in this area, insurance companies can act as helpful partners.”

In summary, the insurance industry plays a fundamental role in relation to the health care provided to any country’s residents. There is still much work to be done, and it will require not just a commitment from the public and private sectors, but in the end, from society in general. New care models can be seen as a step in the right direction.