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The High Performance Health Plan
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Chapter 9

Building Better Care Pathways

Care pathways create a practical route from a member’s question to appropriate, timely care and a more predictable plan outcome.

Core idea

From concept to management action.

Complex care improves when employees are guided before consequential clinical and site-of-care choices are fixed.

Care pathways are the sequence of decisions an employee makes from an initial concern through diagnosis, treatment and follow-up. High-cost care becomes more manageable when the plan supports those decisions early with credible information, timely navigation and coordinated partner roles.

Begin with episodes that combine high consequence and practical opportunity: oncology, musculoskeletal care, maternity, cardiovascular conditions or specialty treatment. Aggregate evidence can point to a pattern, while qualified clinical partners determine the right member-level support.

A pathway should have a clear engagement moment. Define when the member hears about navigation, a second opinion, a center of excellence or case management; what the service helps decide; and how the next handoff occurs. A disconnected vendor menu adds work at the time people need clarity.

Centers of excellence and second opinions require more than a preferred list. Consider clinical credibility, travel, caregiver needs, local follow-up, financial support and member choice. The best pathway is one employees can use and providers can coordinate with.

Measure the pathway with both experience and outcome signals: timely engagement, appointment completion, changes in care setting, member confidence, relevant quality measures and reporting integrity. Start with one pathway, learn and improve.

Chapter knowledge base

Implications for the people who lead the plan.

This companion explains how employers can support complex care as a coordinated pathway instead of reacting only to high-cost claims.

For CEOs

For CEOs, better care pathways can protect workforce wellbeing and reduce the disruption of avoidable complexity.

For CFOs

For CFOs, the value comes from earlier, better-informed decisions rather than retrospective claim containment alone.

For HR

For HR leaders, the critical test is whether employees receive timely, understandable support at stressful moments.

Questions to ask your advisor

  1. 01Which complex-care pathway has the greatest need and readiness for review?
  2. 02When will members be offered support, and who owns the handoff?
  3. 03How will we measure pathway use without reducing success to a savings claim?
Read the high-cost care and clinical strategy guide

What employers commonly misunderstand

Building Better Care Pathways is a one-time project.

The strongest improvements require a regular management cadence, documented decisions and follow-through beyond a single meeting or renewal season.

A vendor report is the same as oversight.

Reports matter when leaders agree on the questions, test the evidence and use the answers to make or adjust a decision.

More activity means more progress.

Focus on the few actions that materially improve care pathways, not a long list of disconnected initiatives.

The answer is identical for every employer.

The right next step depends on workforce needs, risk tolerance, data availability and the organization’s ability to execute.

Questions for leadership

  1. 01What evidence do we have about care pathways today?
  2. 02Which leader has clear decision rights and accountability for this work?
  3. 03What assumption should we test before the next significant plan decision?
  4. 04How will employees experience a better result if we get this right?
  5. 05What would credible progress look like in the next 90 days?

Key terminology

Decision rights
Documented clarity about who recommends, approves and owns a material health-plan decision.
Management cadence
A recurring schedule for reviewing evidence, making decisions and tracking commitments.
Leading indicator
A measure that signals whether the work is moving in the intended direction before final outcomes are known.
Active stewardship
Year-round employer oversight of plan strategy, partners, evidence and member experience.

Related Score questions

  • Can leaders explain the current approach to care pathways and its intended outcome?
  • Do we have timely information to evaluate performance and adjust course?
  • Are responsibilities and next decisions clear across the employer and its partners?

Download the Executive Reading and Action Guide

Use this companion guide to turn Chapter 9's leadership questions into a focused discussion and practical next steps.

Download the guide

Take the next step

Find the work that matters most now.

Use the Health Plan Score to identify where your organization has the clearest opportunity to move from renewal management to active stewardship.

Take the Health Plan Score

Put the methodology to work

Apply the HPHP methodology with Employer Benefits IQ.

Employer Benefits IQ is the practical application platform for employers who want to use education, tools, data, vendor intelligence and decision support in real-world benefits decisions.

Use Employer Benefits IQ tools and decision support