Open enrollment in the year 2020

During this open enrollment season, working families receive in the mail a set of instructions enabling them to select their health insurance carrier and make some important family decisions regarding anticipated spending for healthcare services in the coming year. I'd like to make some predictions about what this arcane process might look like in 2020—just about 5 years from now!

Today, families sit at the kitchen table and ponder all sorts of complex "insurance speak", including co-insurance, deductibles, co-payments, re-insurance, consumer directed health plans, Accountable Care Organizations, and the list goes on. For persons who aren't experts in this, it can seem not only daunting, but downright terrifying! Personally speaking, in our family, with a husband and wife physician couple who have expertise in health policy, we too find the process opaque at best and heart burn inducing at worst. You are not alone!

Most of us who work choose a healthcare plan based on a wholesale market. That is, provider organizations sell themselves to insurance companies, and then employers make decisions on behalf of the thousands of individuals and their families. The technical name for this process is giving employees a "defined benefit" structure from which they can choose a provider and insurance plan. Even in 2014, many employers have moved to a "defined contribution" model whereby they give employees a pot of money and send them out into the marketplace to somewhat blindly choose their doctors and their hospitals.

I predict that in 2020 this model will no longer exist. We will see a complete retail model where individuals working for big companies will make decisions based on their own particular needs, the benefits of the plan, and the individual doctors and hospitals who participate in it. They will customize all aspects of this selection process based on their family. We will do this because of the explosive growth in private exchanges, insurance marketplaces operated by private employers based on the same model as the ACA's exchanges.

In addition to these private exchanges, the healthcare consumer of 2020 will go online and pick a doctor and a hospital just like they pick a restaurant, refrigerator, or new car. In other words, they will read doctor-specific reviews on a Yelp-like platform; they will look at how doctors fared with regard to their communication skills with patients; and they will go onto a government website to see how hospitals have fared with patients in their age group. This will be especially valuable for those of Medicare age.

And the list goes on. We will have complete price transparency and total public accountability available 24/7 online regarding the outcomes of the care that doctors and hospitals deliver. In fact, I think a four word mantra will guide the open enrollment of 2020, and it goes like this, "No Outcome, No Income"—meaning that persons will buy insurance based on getting good outcomes from various providers, and those providers will do better economically by achieving better outcomes.

According to leading consulting companies and healthcare brokers, we are already on the road to this vision of 2020. Nearly 40% of all companies are interested in shifting to this "defined contribution" model, and many are even moving right now to a private exchange plan in order to make this shift. Walgreens employs many graduate-trained pharmacists - nearly 25,000 nationwide. These are highly educated and highly competitive workers who know a thing or two about healthcare. As they start to move to a private exchange, hosted currently by the Aon Hewitt Corporation, this could be the so-called "tipping point" as we rapidly exit "defined benefit" and move quickly to "defined contribution" - all the way to a true retail model for purchasing and consuming healthcare services.

Finally, this 2020 scenario will be fueled by good data on outcomes of all kinds—clinical, economic and social. This 24/7 availability of these outcome measures will facilitate decision-making and help families, even our own, make better purchasing decisions. In the end, I think we'll all get better care at a lower cost, or what every other industry calls "value".

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