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By the time a healthcare claimappears, a lot has already happened.
Someone needed care. Maybe they foundit quickly. Maybe they waited. An earlier interaction may have provided usefulcontext for the next one, or the information may have stopped where thatinteraction ended. Eventually, some portion of that experience becomes visibleas healthcare cost.
Claims give employers and theiradvisors an essential financial record of what occurred. They help usunderstand utilization, identify patterns, evaluate performance, and makedecisions about what comes next.
But claims show us the economics afterthey become visible. They won't tell us that someone waited three weeks becausethey didn't know where to begin, or that a referral died between two systems.Those events may have changed the episode before the financial record existed.
Look farther upstream and a broaderpattern begins to emerge. Across the healthcare journey, at least 18 forces canshape the economics before they become visible—from what happens before someoneseeks care through what happens during care, across the system, and after theencounter.
Most don't look economic when theyfirst occur. They become visible as economics later.
The Small Things That Don't Look Economic
Start with the moment someone needshealthcare.
How quickly can they get help? Do theyknow where to start?
From there, the experience beginsdeveloping a trajectory. The person may encounter a clear path into care orseveral front doors. Information may follow them or remain behind. The nextprovider may have useful context or have to start over.
A delay can allow a condition tobecome more complex. Confusion can keep someone from seeking care while aproblem is still relatively manageable. Fragmented information can contributeto duplication or leave the next provider without context that could havechanged a decision.
Confidence matters here, too. Abenefit can be available, a provider can be in-network, and care can still bedifficult to reach. People have to know which door to open first. Familiaritywith the system can shorten the distance between noticing a need and acting onit.
None of these moments is likely toexplain healthcare economics by itself. Across a workforce and over time, smallvariations compound.
An episode develops a trajectory longbefore it develops a price.
What Happens Before the Outcome?
Employers have become very good atmeasuring what happened through claims, utilization, engagement, outcomes, andcost trends. Those measures are essential. Much of what they tell us isretrospective.
Connected healthcare allows more ofthe journey to remain visible along the way.
Every interaction can add context towhat the system already knows. When that context follows the person, the nextinteraction can begin with what is already known. One encounter can inform thenext decision rather than becoming another isolated event.
Consider engagement. One of theprimary questions around engagement has been whether people use the benefitsavailable to them. Logins, assessments, appointments, and benefit use all tellus something useful.
But what if utilization is the leastinteresting thing engagement can tell us?
Healthcare interactions can provideinformation about changing needs, continuity, clinical complexity, and wherepeople are having difficulty getting through the system. There are importantlimits to how that information should be interpreted. Engagement data is notpredictive on its own, and ordinary healthcare behavior should never bestretched into conclusions about individuals that it cannot support. Privacyand clinical validity have to remain part of the conversation.
If changing healthcare needs becomevisible through engagement before they become expensive claims, engagement cantell us something about the direction healthcare is moving while there is stilltime to influence what happens next.
The earliest evidence of futurehealthcare cost may not always arrive looking like risk. It may arrive lookinglike engagement.
Employers Have Influence Earlier Than They May Realize
Employers cannot control everyvariable in healthcare.
They do make choices that shape theenvironment in which employees experience it.
They decide which healthcarecapabilities are available and how people gain access to them. Their purchasingdecisions affect whether those capabilities connect, whether useful informationcan move between them, and how much navigation employees have to do forthemselves.
An employer can assemble an excellentportfolio and still leave employees moving among disconnected programs. Eachprogram can perform well on its own while information stays inside it. One partof the healthcare experience can learn something important without changingwhat another part of the system knows or what happens next.
Employees experience that differentlythan employers buy it.
Employers purchase healthcare incategories—medical, behavioral health, pharmacy, navigation—often with separatecontracts, budgets, and owners. The person needing care doesn't arrive as acategory. Someone managing diabetes may also be dealing with depression.Someone seeking mental health support may have a physical condition affectingwhat happens next.
The individual capabilities stillmatter. Their ability to work together matters, too.
The value of a healthcare solution isshaped by what happens inside it and by what the rest of the system can dobecause it is there.
How those capabilities work togetheris a question of healthcare architecture.
The healthcare system underneath canbe sophisticated and complex. The employee shouldn't have to become an expertin that system to receive care. The sophistication should live underneath theexperience, where it can help connect people, information, and the nextdecision.
The System Is Responding to Its Design
This is the premise behind HealthcareIs Behaving Exactly as Designed: The Hidden Forces Reshaping Employer Healthcare.
Every healthcare system containsincentives, structures, information flows, and expectations. People andorganizations respond to them. Repeat those responses across enoughinteractions and the effects eventually become visible in healthcare experienceand economics.
The 18 hidden forces trace some ofthose effects from before care through the point where employers finally seethem in the numbers.
Access has little value until someoneuses it. Engagement begins before there is a claim. Fragmentation transferswork to the employee. Where care happens changes what it costs. Continuitychanges what happens next. AI can accelerate incentives already in place. Bythe time an episode becomes a claim, much of its story has already beenwritten.
Seen together, the forces revealsomething employers may be overlooking.
They have less control over healthcareprices than they would like. They have more influence over the conditions thatproduce those prices than they typically use. And that influence existsearlier.
What Can Employers Do Earlier?
Seeing the hidden forces is usefulonly if it changes what we do with them.
The manifesto follows the 18 forcesinto six areas where employers can begin influencing the system earlier:changing the conditions that produce the economics, moving influence upstream,making healthcare easier to use, designing around the whole person, aligningeconomics with the outcomes they want, and measuring more of what happensbefore the claim.
None of that gives employers controlover healthcare. People will get sick. Serious conditions will requireexpensive treatment. Medicine will remain uncertain and complex.
There is a lot of room, though,between controlling everything and having no influence at all.
Employers operate in that space everyday through the systems they purchase, the incentives they create, theexperiences they make available, and the expectations they set.
Healthcare economics don't begin whenthe claim arrives. The claim is where they finally become visible.
The opportunity is to use theinfluence employers already have earlier—while there is still somethingmeaningful to change.
So what should we design next?
Explore the 18 hidden forces shapingemployer healthcare—and six ways employers can begin moving influence upstream
Explore Healthcare Is Behaving Exactly as Designed: The Hidden Forces Reshaping Employer Healthcare →
