The Central Penn Business Journal sat down recently with John Lufborrow, vice president of sales for Highmark. In this conversation, Lufborrow dissects the trends in employer-based plans, the broad relationships and connectivity Highmark has developed in Pennsylvania and the importance that a well-informed, connected payor has in the employer-based health care relationship.
CPBJ: This question arises often: cost. Is that a mistake to consider only cost? Is that somewhat just shortsighted. Can you walk us through that?
Lufborrow: Considering cost is important, but it’s part of a bigger equation. An overall perception is that insurance or health insurance is a bit of a commodity. As long as you have it, then you’ll be able to kind of get what you need and you might as well go with the lowest price.
When you have to make healthcare decisions, you realize it’s not a commodity market. There can be significant differences between one carrier or one payer and another.
Employers should have cost in their equation, but really what they should be thinking about is value, and that’s where our focus is with Highmark. Value isn’t just high quality doctors and providers and hospital systems. A big part of value is the experience. We have over a million health plan members in the 34 county-area. We have over four million members in the state of Pennsylvania alone. You don’t reach that large customer base without being able to walk that balancing act and deliver the best in class experience.
CPBJ: Why is care management so important?
Lufborrow: The idea of managed care is helping members — patients — navigate their health care journey. The payer’s responsibility is to make it really easy to get the care they need. Sometimes that means advocating for more care. Take a diabetic patient, for example. What if we’re finding out that they’re not getting the care they need. Maybe over the course of a year you find they’ve gone to the emergency room 10 times. The managed care team can work with that member and help them avoid these trips to the ER. That’s where the payer sits in the middle. There is this triangle. There is always a patient, there is a provider, and then there is the payer; and all three of them have to be on the same page and working together to help deliver that best experience. The only person that can really see the total picture for that member is the payer. We need to lean in and advocate for them.
SUBHEAD: Data drives insight
Lufborrow: With Highmark, 97 percent of the physicians are in our network and 98 percent of the hospitals in the state of Pennsylvania are in our network. We have really good insight as to who are the best providers in any given area. We want to make sure we’re creating a really easy way to elevate a member in the health care continuum. Imagine you got a phone call today and someone was telling you, hey, look, you’re getting ready for knee surgery. We see the prior authorization, but you’re lined up with a surgeon who is really like in the bottom 30 percent of surgeons in that area. We would find a tactful way to be able to kind of nudge that member and help them get to a second opinion.
CPBJ: That care management actually benefits your employer and the cost?
Lufborrow: Yes. So there is a lot of data that an employer can evaluate to determine whether or not they’ve picked a great partner and a big part of that is looking at their macro level trend data. This is really important especially for self‑funded employers. They want to make sure that they’re evaluating the performance of the plan that they’ve picked and the carrier that they’ve picked.
SUBHEAD: Engaging market stratification
Lufborrow: We are always trying to innovate and look for new ways to engage with members. There is a giant stratification between all of our types of members, whether it’s the 88-year-old, the senior market, Medicare member, or that 18-year-old, who got their first job that has medical benefits through their employers. These two individuals are going to have different ways that they’re going to want to engage with us.
So we’ve got to be malleable. Because if you can’t engage with them, then you’re missing that whole part of that payer being able to come in and say, hey, we want to help you. We see some things that could be impacting you and we want to make sure that you’re getting that opportunity to get the best care. Let us talk about options.
CPBJ: When an employer is interested in the group health plan for their company, what Highmark’s approach into meeting their needs?
Lufborrow: Everything really starts with the customer. So you have to understand what your customer’s needs are. When I speak from a customer perspective now, I’m saying the employer group. And we are fortunate to have a very diverse group of employers as our clients so everything from every type of industry. It allows us to be very customer centric and very focused on what their needs are.
A food manufacturer in Berks County which has, maybe 3,000 employees is going to have some different needs than a law firm in Harrisburg. So it starts first by really understanding what their individual goals are. You have to make sure you work with the groups and you’re in tune to what they’re looking for and what their expectations are. They come to us already with some ideas and some thoughts and a vision and then we can very quickly partner with them to make sure that we’re able to deliver. That’s, again, another nice advantage of a company the size of Highmark. We’ve seen a lot of different types of groups and employer groups and we have built a lot of tools and plans that they need to be successful.
COVID‑19 has forced a lot of employer groups to reevaluate, to take another look at their benefits. And if they’ve been in a tough financial position, they may want to say, hey, we’re going to pair down some of the benefits that we offer and try to find additional value so that they can continue to operate as a business or continue to grow or expand or meet our business goals. Highmark is ready to be able to partner with them in that regard.
CPBJ: What would you recommend as a regular touch-base standpoint with employers regarding services?
Lufborrow: Best practice, seems to be at least twice a year. The engagement from most of your employees seems to be pretty high at the beginning of a plan year. So when they’re going through open enrollment … I think you want to also do a pulse check in the middle, because it is really important to hear from your employees and it’s a way for them to stay competitive and to retain and gain great talent. All the benefits when you put them together, medical benefits, are something that I think (prospective employees) check right away. I think they do need to do that kind of evaluation and reevaluation at least twice a year.
CPBJ: What can you share with our readers in relation to population differences? An employer in Perry County might have different needs compared to downtown Harrisburg?
Lufborrow: Someone that is predominantly in a more rural area is going to have some unique needs. The biggest one that comes to mind is access. Access can be a lot of different things: access to good primary care, access to specialty care, and access to hospitals. The payer can see the full landscape and the payer has the opportunity to help guide that member, that patient, to the right level of care that they need.
Think of some of the systems that we partner with in this region, Penn State Health, Lehigh Valley Health Network, you know, Geisinger up in the northeastern PA area. These are kind of our big provider partners, but we also partner very closely with WellSpan and Lancaster General. We have an opportunity and we see kind of gaps in care or gaps in coverage, we reach out to these partners and we let them know what we’re seeing from a macro data system.
The other thing is a technology. So one of the things that has exploded of late because of the pandemic is virtual medicine. The pandemic forced it to be an accepted thing now much more broadly and that’s good, especially for rural parts of Pennsylvania.
You’ve got to make sure those rural areas are covered and it can be by driving expansion of existing systems into those rural areas. That expansion is driven by data that Highmark shares with them. If you’re wondering what’s happening behind the scenes, it’s a lot of that type of stuff, because that data ultimately gives those members the best possible experience.
CPBJ: Is there anything I’m missing here that maybe we should be talking about that we didn’t get a chance to chat about?
Lufborrow: Throughout central Pennsylvania is Highmark Blue Shield, as most of us know us out here, is certainly highly capable and an important part to the broader Blue Cross Blue Shield Association. We are part of a much bigger company and that company is Highmark Health. It owns United Concordia Dental. It owns a stop loss or reinsurance company called HMIG. It owns a data company called Highmark Health Solutions. And it also owns a very large health system in western Pennsylvania. We have the capability to be able to be, like I said, this, you know, this kind of comprehensive healthcare solutions company, for employers and that’s very different from a lot of our competitors.