Value-Based Care Can Turn Healthcare Around, Data is the Key

According to the most recent numbers from Centers for Medicare & Medicaid Services, healthcare spending represents 17.7% of the U.S. Gross Domestic Product, growing to $3.8 trillion in 2019. Americans spend more money per capita on healthcare than any other country in the world. However, as life expectancy is increasing across the globe, it has actually declined in the U.S. since 2014.

Healthcare costs are out of control, and value-based care is recognized as the most significant initiative that can turn things around. With the fee-for-service model, the healthcare system is waiting to treat people who get sick. With value-based care, the providers get paid for  keeping patients healthy and avoid expensive encounters and hospitalizations.

The concept of value-based care is the opposite of how the U.S. healthcare system operates today. So naturally, there has been resistance by both health plans and providers. The fee-for-service model is so entrenched in care delivery that providers rely on a constant revenue flow when paid for treating patients. And while providers are interested in making patients healthy, proactively keeping patients healthy is an entirely different approach to care. The burden is on the provider to ensure the patient receives preventative treatment; this requires keeping up with people, making sure they’re proactive with check-ups and other services, and taking medications, among other things.  It also means that providers must take on some of the risk that health plans have traditionally borne.

For successful value-based arrangements, health plans must provide actionable data and analytics to the providers. In order to hold a primary care physician (PCP) accountable for a patient’s health outcomes, the health plan must offer a comprehensive, 360-degree view of the patient and their claims and encounters.

For example, if a patient with diabetes goes for an annual eye check-up—which they need to do—their health plan must provide that data in an easy to consume way for the physician to know what kind of care the patient is receiving. It’s up to the health plan to provide the data that lets the PCP know everything about the patient’s condition and treatment. Without the data, the PCP will be disconnected from the actual maintenance or proactive steps a member needs to take to stay healthy, often resulting in costly treatment.

In a recent webinar, HealthEdge customer Eric Decker, SVP of Information Technology and CIO at Independent Health, shared that his organization has value-based arrangements with 100 percent of their primary care physicians. They understood that information sharing was critical to the success of these agreements. To effectively share data, they built capabilities available to the PCPs in their provider portal to communicate with the providers with scorecards that show how each physician is performing relative to their peers and view outstanding gaps in care.

If the entire healthcare system embraced value-based care, everyone would be working together to keep patients healthy. With value-based care, the quality of care and outcomes that come from preventative measures will keep costs down and, hopefully, cause life expectancy to climb back up.

Our Ongoing Commitment to Diversity, Equity and Inclusion

HealthEdge’s culture values a deep sense of community, understanding, and most importantly, belonging. We want our employees to know that HealthEdge strives for an inclusive environment that welcomes people of all backgrounds, ideas, and voices. That’s why HealthEdge created iBelong, an internal group that has regular, open conversations about diversity, equity, and inclusion and discuss ideas on how we, as a company, can do better.

In October 2020, HealthEdge took our commitment to diversity and inclusion a step further and joined MassTLC Compact for Social Justice. As part of this initiative, we promised to introduce and expand educational programming related to diversity, inclusion, racial inequality, managing diverse teams, and creating a judgment-free culture.

It was important from the beginning that our employees had a voice and drove the educational content by helping us identify the most impactful topics. A few members of our iBelong group worked together to define what we wanted to accomplish with the programming. They also volunteered to take the training before we launched company-wide to provide feedback on what resonated and what was missing.

We realized quickly that the training needed more than just definitions of diversity and inclusion. The number one question we received was, “what can I do to make a difference?” To make an impact, the sessions required actionable information with steps employees can take to create a more inclusive workplace. For example, certain sessions took deeper dives into recognizing unconscious bias and steps to overcome your own biases, as well as the LARA/I method of active listening that opens the door for meaningful conversations and connections. We encouraged all employees to complete the courses and begin to take actions that will help us progress toward expanding our diversity and inclusiveness.

We understand that we cannot create a diverse, inclusive, or equitable workplace through just emails or handouts; we need to build trust and strong relationships. We want our employees to feel comfortable talking to each other about difficult topics, sharing their points of view, and make these discussions part of our culture.

The next step is to build on what we’ve learned through a speaker series. The series will take the concepts we already introduced and take a deeper dive into what does it mean and how as a culture, we can get better, be more diverse, make sure everyone feels included.

David And Goliath: Smaller Health Plans Can Remain Competitive With The Right Technology

As all health plans have continued the conquest of adding lives to their risk pools, the industry has witnessed vast membership consolidations over the past decade, resulting in a shrinking number of smaller regional plans operating independently.

Looking at the payer industry today, there are only a handful of major players left spread out across the nation. Almost every regional plan is becoming a subsidiary of those larger entities. As these smaller plans are acquired and absorbed into the landscape, there often comes a system consolidation of the core platforms fueling a competitive market for the remaining opportunities that evolve.

The larger the enterprise is, the harder it seems to implement change. That’s one reason why so many larger insurance providers take the minimum viable product (MVP) approach to reinvent themselves because they become stale, stagnant, and are too huge to create meaningful change. A common strategy is to take one of these smaller regional plans and rebrand that smaller plan using the MVP approach.

How can smaller payers continue to compete against larger payers as they continue to grow and add lives? How do they create operational efficiencies and lower PMPM costs?

One obvious way a health plan can gain efficiencies is through technology. However, it should be mentioned we must embrace the culture of change when implementing a new core solution. Often new software solutions can be the adversary to existing states.

Technology is just a tool, after all, so it is really the ability to adopt and master the application that determines the new solution’s success.

From a technology view, once the playing field is leveled, it becomes the savvy users who understand the system advantages; those who can embrace change often determine the outcomes of success or failure. Those that will ensure your organization is not “paving the cow path” and recreating a legacy approach in a modern system nor achieving inefficiency faster.

For additional competitive advantage, if a smaller health plan adopts new technology, should they truly partner with the software vendor for success —they will continue to gain efficiencies, remain competitive, and get further, faster.

Without a direct partnership with our customers, success can be challenging at best.

A great example of that investment or partnership in the effort to increase system adoption is providing end-user training. While initially is crucial, ongoing training is especially critical to build the culture of continual optimization.

As my colleague Wilda Todd wrote, smaller plans with fewer resources to invest in training are not alone! They should lean on their vendors and leverage their knowledge and expertise, not only in training but in all the many aspects of building the ecosystem and total solution.

Preparing for Regulatory Changes from the New Administration

With the new presidential administration coming this week, most experts are projecting significant shifts in the healthcare space, especially related to health insurance coverage.

Some changes may come faster than others, but one thing is clear – healthcare is the dominant issue for the Biden Administration. Proposed changes range from regulatory actions related to the Public Option, Medicare, prescription drug reforms, and rules related to the Affordable Care Act, short-term limited-duration plans, association health plans, and Medicaid programs.

According to the Health Research Institute at PricewaterhouseCoopers, “Broadly, healthcare executives can expect an administration with an expansionary agenda, looking to patch gaps in coverage for Americans, scrutinize proposed healthcare mergers and acquisitions more aggressively and use more of the government’s power to address the pandemic.”

If health plans are managing policy updates and fee schedules internally, the responsibilities are ever-increasing. With Medicare’s major quarterly updates being augmented by policy adjustments (such as COVID-19 vaccine administration policies and the Final Rule for 2021 Medicare Physician Fee Schedule, which includes new telehealth provisions) and retroactive changes, fee schedules require constant maintenance. The new administration’s focus on healthcare reform will only add to this workload.

To address the many changes on the horizon, health plans need to automate these processes and make it easier to handle the lift associated with regulatory updates. They need technology solutions backed by policy experts that take care of the research and manage and load in fee schedules automatically, with rates and payment policies modified, tested, and operational on or before the effective dates.

Cloud-based delivery of up-to-date Medicare and Medicaid policies and fee schedules loaded and configured in a way that meets their specific business needs, mitigates risk from a compliance standpoint while simultaneously giving health plans a competitive advantage.

With the right technology, health plans don’t need to worry about the new administration’s policy changes impacting their day-to-day business operations but can instead remain agile to new regulatory actions and a shifting marketplace. Which area do you want to focus on to bring the most value to your health plan?

Creating a Culture Where Employees Proudly Bring Their Whole, Authentic Selves to Work

Prioritizing Diversity, Equity, and Inclusion (DE&I) and is critical for an organization’s success and a company culture that creates a sense of belonging.

When I joined HealthEdge in June 2020, I knew the company valued DE&I, and I was excited to build on and formalize our existing efforts.

We started by looking at our organization’s makeup in terms of diversity and our representation across gender, ethnic, social, economic, religious, and personal backgrounds. As a company with a multigenerational, multicultural workforce, we know everyone has different experiences that may impact how we relate to one another. This summer, we launched the iBelong group to allow everyone to continue learning and growing by sharing their unique perspectives through regular conversations.

Every iBelong meeting is different; we have watched and discussed Ted Talks, reacted to articles, and invited internal or external guest speakers to present. The goal is to create a space where everyone can feel like they are a part of a bigger, broader community and included in the work we are doing.

In just six months, the iBelong group has grown across the organization to nearly 200 members, who all agree that DE&I is essential, and they want to be part of the path forward.

With the support of iBelong, we’ve made significant strides as an organization. We added Juneteenth as a company holiday and sponsored programs for LGBT awareness. We signed on to MassTLC Compact for Social Justice, making the commitment to improve our self-reporting of demographic data, increase racial diversity in talent pipeline development programs, and introduce educational programming, including a company-wide DE&I training series that launched in October. And, VentureFizz’s Lead(H)er series, which spotlights impressive women leaders in the Tech Industry, featured Laura Tomaino, HealthEdge’s VP of People and Culture.

Although I’m proud of what we’ve accomplished so far, the work is far from done. We actively ask for input and feedback from our employees to ensure we deliver relevant programming and opportunities that resonate with our workforce, as well as address any issues that may impact the employee experience.

The combined efforts, enthusiasm, and commitment to DE&I from colleagues at all levels across the organization ensured we could build on this momentum, be proactive, and work toward creating an environment and culture that allows our employees to feel comfortable and proudly bring their authentic selves to work.

Opportunities, Collaboration and Innovation in 2021

The biggest issue facing payers today is that their business changes every year. The pressure to develop reimbursement methodologies with providers that account for the quality of care, access to care, and value-based payment models has increased. Regulatory updates, the worldwide pandemic, and ever-present competition impact payers on an ongoing basis. There are also growing requirements for payers to transact with their members, providers, and employer groups in a modern way. Take Amazon and other B2C businesses; as consumers, we have become accustomed to an easy online buying process and have come to expect this with all transactions.

These collective stakeholder demands have resulted in an industry required to act, behave, and structure its activities in a completely new way. At HealthEdge, it’s our goal to get out ahead of that and help our customers meet, and exceed, these expectations.

We believe that health plans deserve to have a highly automated, accurate, real-time computing infrastructure, and we know our core HealthRules® product, while serving as the heartbeat of key payer operations, can’t do it alone. That is why in 2020, we acquired Burgess Source® to add claims payment accuracy, pricing, and editing, complementing and enhancing our existing adjudication capabilities and most recently Altruista GuidingCare®, the most successful modern care management platform in the marketplace. Our customers can come to work with us for the first time through any of the three products, as they are available on a standalone basis today and in the future and can work with any technology infrastructure in the market.

The integration of Burgess Source and GuidingCare with the HealthRules core administrative claims processing system allows our customers to experience significant benefits from the combined capabilities.

We’re bringing together best-in-class solutions that drive the three most important value streams within a health plan. These value streams cut across the administrative costs of running the business, the medical expenses of paying claims, and the effort to help members with acute or chronic conditions comply with their treatments and obtain better care and better lifestyles.

These integrated solutions make possible a vision where claims processing is enhanced with software-driven payment integrity at the point of service that feeds data to an end-to-end care management solution.

With three, next-generation, cloud-based applications, this combined solution suite is the first-of-its-kind. While each product is viable and extraordinary on its own, we believe the unique value is how these applications work together, enabling automation and workflow efficiencies in a meaningful way. Other options in the marketplace can take years to connect to one another. HealthEdge already has health plans across the country successfully using a combination of these products.

Together, HealthEdge, Burgess, and Altruista empower customers to effectively compete and be resilient to changes in the healthcare marketplace. We will continue to build out from our core system and enable our customers to add next-generation technologies that lower administrative and healthcare costs while improving patient outcomes and quality and supporting regulatory compliance.

As we embark on the new year, I am most excited to accelerate our levels of collaboration and innovation so we can continue elevating health insurance and healthcare.