Aetna chief executive Mark Bertolini heads one of the biggest health insurers in the country and is on the cusp of a $69 billion megadeal to merge his company with pharmacy giant CVS. He says the future of health care is going to depend, mostly, on the time people spend outside the grasp of the traditional medical system.
Health-policy experts increasingly talk about the effect of Zip codes on health — an acknowledgment of a growing body of research showing that where and how people live can have a bigger influence on their health than interactions with the medical system or even genetics. That means health insurance has to evolve, Bertolini said in an interview — away from acting only as a payment system for procedures and drugs when people are ill and toward interventions to help people stay healthy in their everyday lives.
“Right now, we sell a warranty card. You come to us in case of breakage. We indemnify you against loss when you have breakage; you present your warranty card to the provider,” Bertolini said. He noted that of the roughly 6,200 hours people spend awake each year, only about 20 of them are spent in the medical system — meaning most traditional health-care companies are missing an entry point into the behaviors, environment and lifestyle factors that actually shape people's well-being.
Bertolini sketched a vision of the future of health care in which a combined CVS-Aetna could instead be a gateway to health, a first stop for consumers with health issues. Pharmacists or medical professionals in a neighborhood health hub could help schedule people's appointments or focus on nonmedical forms of help, such as coordinating rides, meal assistance, nutrition counseling or social supports. Wearable technologies monitored by health professionals could help people stay on the right medication regimens or flag health problems before they evolve into an emergency. CVS's brick and mortar locations would give both health-care companies a foothold in the time Americans spend awake each year.
“Part of our deal with CVS is that we can push the financing, the insurance, to the back of the building, and instead, think about this investment in the local community, given 10,000 storefronts,” Bertolini said. “We could make provisions for rides by Lyft, or Meals on Wheels, or fuel assistance for food or socialization.”
To understand how to focus such efforts, insurers need to first understand where the problems exist.
The Aetna Foundation partnered with U.S. News & World Report to rank the healthiest communities in the United States, grading them using measures that included access to care, to housing and to education. Several affluent communities in northern Virginia ranked in the top 10, and Falls Church led the country. The Blue Cross Blue Shield Institute also launched this month, with a data tool to probe the “Zip code effect” on health and help identify transportation and pharmacy deserts that could be addressed with transportation solutions, such as Lyft.
Whether health insurers will be able to successfully attack the complex web of social factors that feed into people's health remains to be seen, but Bertolini argues that understanding where problems exist is an important first step.
For a long time, insurers have been focused on containing costs by shifting them onto consumers or requiring physicians or nurses submit prior-authorization paperwork to prove their patients really need expensive treatments. The delays and resources required to get medically needed treatments approved have become a constant complaint among physicians, and several states have announced they are scrutinizing Aetna's process for prior authorization.
Bertolini said this entire dynamic of trying to restrict access to care could be transformed and even eliminated if CVS-Aetna is able to partner with patients. If patients are willing to let their insurer in to help make medical appointments, coordinate care and monitor their health in between appointments, for example, it could mean no more co-pays or prior authorizations.