By Michelle Anaba
Policy Project Manager, Health
You’ve probably heard the adage “Give a man a fish, you feed him for a day. Teach a man to fish, you feed him for a lifetime.” But why not teach a woman to fish? Or what if the fishing source is polluted or barriers prevent the potential fisherman from reaching it? These are some of the questions Rishi Manchanda, M.D., founder and CEO of HealthBegins, posed during his keynote address at the Academy’s recent Broadening the Focus Health Summit to prime the audience to focus on fundamental assumptions and issues.
This virtual event, organized by the Health Equity Committee (HEC), was a capstone conversation featuring discussions by actuaries and subject matter experts on ways to improve healthcare access, quality, and affordability by broadening the focus beyond return on investment (ROI) to a more holistic view of efficacy and value. The HEC also used this opportunity to introduce a new Broadening the Focus framework that outlines this approach.
Manchanda founded HealthBegins to promote the importance of measuring health care value in different ways, how health outcomes unfold over time, and the potentially negative results of evaluating health care interventions based solely only on traditional financial metrics. He said more time needs to be given to weighing the health needs of individuals. “We see aspects of their lives in claims data, but it’s not often that we listen to the stories hiding within the data,” he said, adding that it’s important to factor in key non-medical challenges that patients may face and that affect health and access to care, such as inadequate housing, food insecurity, and transportation challenges
Manchanda praised the Academy’s project and its principles-based framework, which supports examination of health care program efficacy beyond ROI. The framework is also designed to take into account some of the social barriers to accessing care and why it’s important to track more long-term health outcomes that are not reflected in ROI-based evaluations.
Introducing the Framework
HEC Chairperson Becky Sheppard and committee member Ugo Okpewho introduced and explained the Academy’s framework, which is detailed in a recently published issue brief. The framework is the cumulation of more than a year’s worth of work by the HEC, reflecting the input of many stakeholders, including actuaries, clinicians, insurers, policymakers, and employers. It is intended to support a more effective and complete health program evaluation process. The framework follows up on a series of issue briefs by the HEC that reported on the results of their extensive consultative process, which included interviews, webinars, and a town hall involving a broad array of experts.
“The framework surfaces considerations—it complements, rather than replaces—existing evaluation measures,” Sheppard said. “It doesn’t recommend models or statistical techniques. The goal is to make better use of health care resources and support outcomes that improve access, affordability, value, and outcomes.”
Okpewho stressed that many of these discussions were held with people who make operational healthcare decisions as well as actuaries who use ROI in conducting program evaluation to explore health program decision-making. He explained that relying on ROI as the sole metric, which focuses on financial savings, overlooks other potential measures of success, such as quality of life, long-term health/life improvement, and patient experience and satisfaction. He also pointed out that equity-focused programs can be held to a higher standard than traditional health care approaches, with a fuller accounting of potential bias and limits on decision-making.
Sheppard pointed out that many benefits of taking a holistic approach to health care that improves patient outcomes—which can also be financial—are not captured by a focus on ROI, such as improved health care workforce productivity and retention, management of disease progression, and shifts in care settings. She also stressed the need for cross-disciplinary communication and shared terminology, along with cohesive approaches to program evaluation and ensuring that equal weight is given to both financial and non-financial considerations.
Both presenters stressed that the framework is intended to serve as a guide to driving the discussion of how best to shift health care program evaluation from primarily ROI-focused to a more holistic approach.
Other expert speakers did a deeper dive on two separate panels into how the framework could be applied. Deborah Steinberg, senior health policy attorney at the Legal Action Center; Mila Kofman, executive director of the DC Health Benefit Exchange Authority; Rachele Hendricks Sturrup, research director of Real World Evidence at the Duke Margolis Institute for Health Policy; and Tatyana Kotlovskiy, an actuary at Optum Health, addressed its usage in the areas of employer-provided behavioral health and substance use. Meanwhile, Sara Teppema, HEC vice chairperson, moderated a panel looking at food-based interventions designed to support cancer patients featuring Laura Makaroff, senior vice president of prevention and early detection at the American Cancer Society; Kofi Essel, food as medicine program director at Elevance Health; and Julian Xie, director of Medicaid and benefits integration for Share Our Strength.
Conclusion
The summit highlighted the limitations of evaluating health care programs solely through short-term ROI and the importance of considering a broader set of outcomes, particularly for programs designed to address social needs and promote equity. As Manchanda emphasized, many drivers of health and health care utilization unfold over time and remain hidden when evaluation is limited to claims data and financial returns.
The framework is a tool to complement—not replace—existing evaluation approaches by surfacing critical questions about program goals, equity impacts, and long-term value. By encouraging equal consideration of financial and nonfinancial outcomes, the framework supports more informed decision-making and a more complete understanding of program effectiveness.
Intended to be an evolving tool, the HEC invites suggestions on ways to use the framework and how to enhance it. As it continues the conversation, several members of the HEC will present the framework at the upcoming SOA Health Meeting.
All stakeholders are encouraged to read the Academy’s issue briefs on this project, experiment with the framework in health care and other relevant settings, and share feedback with the Academy. For more information on the work of the HEC and the Academy, be sure to visit actuary.org, where you can find information about volunteering opportunities and learn how to invite the HEC to present the framework and its recent work.