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Defining health plan value – what’s really important

If your health plan could show it:

  • reduced the days kids stayed home from school due to illness;
  • helped members with mental health conditions maintain a high level of functionality and engagement;
  • reduced workdays lost due to illness;
  • sped recovery from illness and injury; and
  • helped amateur athletes avoid injury and recover quickly;

would that be important?

Heck yes.

So…why don’t healthplans do that?

It’s doable – if they stopped focusing on and worrying so much about star ratings and patient experience and net promoter scores – which research shows consumers don’t really pay attention to or care about

(conclusion – no.)

and focused on what consumers really care about – staying healthy and able to do the things we want to do:

  • play with our kids and grandkids
  • do chores around the home
  • do our sports
  • shovel our walks, rake leaves, coach youth sports
  • lift stuff and move it around
  • got to the bathroom without help
  • dress and undress without help
  • go for a walk
  • oh, and work.

What’s even more puzzling is why employers don’t demand health plans complete on the basis of delivering fully functional, engaged workers.

What does this mean for you?

The most important component of any organization is its workers.

No employers hold their health plans accountable for ensuring those workers can actually, you know, work.

And that is why our healthcare system is so dysfunctional, ineffective, and expensive.

4 thoughts on “Defining health plan value – what’s really important”

  1. Hi Joe, great post! I often think about these things as wellness and have seen some health plans give premium discounts or rebates for exercising, eating right and limiting alcohol-tobacco use but unfortunately not enough.

    1. Thanks Bryan – those are certainly helpful – it would be even better if healthplans actually measured the impact of those efforts and reported the effect on functionality…

      be well Joe

  2. Joe, that’s quite a list you made. What’s common about the items in the list, is that it takes having the ability to move, have strength to lift, have balance and coordination, and use proper body mechanics. There is a provider expert uniquely qualified to help companies keep their workforce healthy, and doing the work they were hired to do. Physical Therapists are doctors trained in prevention, wellness, screening for work and sports participation, body mechanics, and rehabilitation.
    You can find out more here at
    Most health plans don’t really hold themselves accountable to companies paying the premiums. To these companies they process claims and manage costs in silos. This type of management causes health plans to miss your point. They don’t see what is really going on in the company or connect the dots, which causes them to miss your point. In their current operations they are not setup to do what you or any business really wants them to do, which is keep the worker healthy and working. The number of self-insured companies increases every year. Even still the majority of the self insured are being managed by a TPA that follows the same management being provided by the health plans. Companies really need to look elsewhere to get what they want for their workers. A good place to start is your local independent physical therapy clinic. The owners of these clinics are accountable to the customer and understand how to deliver value that delivers positive outcomes to the workers and improves the company’s bottom line.

    1. thanks for the note Craig.

      I’d note that PT is an important part of the solution – but only a part. PT and its cousins OT and chiro are post-event care and while helpful indeed, are processes, not outcomes. Further, managing chronic diseases involves behavioral health, medication adherence, health monitoring, and effective triage – as well as Physical medicine.

      Companies and consumers should demand healthplans assess and report on member functionality – yes its hard, but that’s their fundamental job.

      Until they do, healthplans will continue to demand and likely receive lower prices from PTs and higher premiums from buyers with little justification for either.

      be well Joe

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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