Breaking Down Silos for Improved Member Experience

EHRs, mobile devices, wearables, claims data, and population health analytics can provide enough healthcare insight to improve outcomes at lower costs. But as the use of technology and data increases within healthcare, the challenge of effectively using that data also grows. The problem is that data exists in silos.

Recognizing this, payers are increasing their investment in innovation. According to our recent survey of 222 health plan executives, 50% said they plan to make significant investments in innovation to achieve their organizational goals this year—up from 19% in 2018. While there is a consistent pipeline of disruptive applications in the marketplace, few effectively connect the key constituencies, which the industry needs more than ever.

The McKinsey Global Institute estimates that the volume of healthcare data and the industry’s inability to take advantage of it, for whatever reason (HIPAA, old technology, business strategy, etc.), leads to potentially more than $300 billion annually in wasted value.

The first step to solving this challenge is better collaboration amongst payers and provider organizations. For payers and providers to align on shared goals, they must share critical data. Both administrative and clinical data can contribute to providers taking important proactive steps to get or keep their patients healthy.

Whether directly or indirectly impacted by the Interoperability and Patient Access Rule, new market demands to equip stakeholders with information that enables them to understand and orchestrate their health care needs and opportunities will challenge the entire health ecosystem. Payers will require administrative capabilities that can deliver exceptional data integrity, data insights, and data access – to their members and the stakeholders who contribute to their care.

Furthermore, health plans that make accurate data directly available in real-time to their members and physicians within their networks benefit from greater efficiency. Customer service representatives spend more time efficiently resolving individual queries or speaking with more members on a daily basis, for example.

For members, it means they walk away from a shorter conversation with the right information or go in armed with the correct data to have a productive call – no frustrated call-backs necessary. The downstream impact of this? Increased member satisfaction—a top goal for health plan leaders— and greater likelihood of follow-through on care plans or better medication adherence to stay healthy.

Healthcare has a formidable challenge that persists: break down the silos between all key stakeholders. Only with technology that provides accurate data in real-time in a consumable manner by all will this occur. Of course, the players in the healthcare ecosystem have to want to collaborate and make the best use of these insights. Once that happens, better outcomes and an improved patient experience are inevitable.

Why Medicare Advantage Plans Have the Most Satisfied Members

While it may not have been a completely shocking revelation, I was excited to see one of the results of our recent survey of 3,000 consumers indicating that Medicare Advantage (MA) plans have highly satisfied members, with 55% of respondents with MA plans giving their insurance providers five stars.

MA has been an explosive area of growth for many of the health plans that we collaborate with. In many cases, it’s been a whole new line of business for organizations, or even the basis for some new health plans startups; for others, it’s been the expansion of their existing MA business in membership numbers or geography, or both. Not only is there still a large portion of the baby boomer population aging into Medicare, but increasing familiarity with and understanding of MA offerings opens the opportunity for conversion of existing members from traditional Medicare and Medicare Supplement to MA plans, including some of the older Medicare population.

With this growth opportunity comes a highly competitive health insurance marketplace, making a positive member experience critical to retaining members and growing the business. And health plans have delivered. Again, it’s not overly surprising that MA received such satisfactory scores; it’s a very high-touch, highly regulated business, down to the communications that need to be delivered appropriately and timely to that high-utilizing population, who rely on and appreciate the visibility.

On the flip side, health plans individually purchased on a public exchange received the lowest satisfaction scores from the consumer respondents, with almost 25% of respondents giving their plan a 2-star or 1-star rating. Furthermore, more than half (52%) of these members plan to scan the market during open enrollment. These statistics, along with the documented recent growth in the ACA coverage as more Americans have signed up on the federal exchange since its reopening, signify an opportunity to increase satisfaction in order to gain and retain ACA members. As health plans analyze these findings, they may consider investing or reinvesting and improving their ACA offerings.

Given the disparity in satisfaction levels between Medicare Advantage and ACA members, health plans with both lines of business have a significant opportunity to take advantage of lessons learned. They can look at both the regulated activities and best practices that have evolved in their Medicare Advantage business to see what could be applied to individual ACA plans to improve the member experience― bearing in mind, of course, the variances in funding and other regulatory activities in these distinct markets.

Additional results of the consumer survey clearly indicate that members across product lines want to fully understand their benefits and to be equipped with self-service tools that allow them to navigate and utilize their plans effectively – ultimately, to successfully manage their health.

Based on these findings, health plans may want to consider evaluating the effectiveness of existing communications and opportunities for enrichment, as well as assessing the underlying technologies and customer-facing tools in place to meet their populations’ needs.

Promoting from Within: How Two Former Interns Climbed the HealthEdge Ladder

Finding New Ways to Deliver Care, While Controlling Costs

Existing fee-for-service payment models are not scalable. Across the industry, there is an increasing emphasis on finding ways to deliver quality care while controlling costs. Health plans are transitioning from those older arrangements to new types of value-based reimbursement. There is a wide variety of effective value-based arrangements; this shift requires health plans to have the flexibility to negotiate, test, and implement a variety of payment models with more science and data behind them.

Especially on the national level, we’re seeing a conversion to using Medicare as a benchmark to make more informed decisions because it has one of the most robust data sets. For example, a health plan may use that as a reference point and decide to pay a specific percentage of Medicare, and then create some additional benefits for maternity care, different types of rehab, or cover more dental services or vaccines, among other things.

National payers need access to real-time data to find the best way to structure agreements that support their goal of providing quality care while keeping costs low. They require technology with the business intelligence tools to model and forecast different pricing scenarios, customizations, and edits to see the best way to transition from fee-for-service to value-based care reimbursement.

When taking a value-based approach, it’s crucial for health plans to have all of the information up-front and understand the impact of specific determinations on their providers. The ability to model arrangements using existing claims and run reports before putting them into place allows health plans to make informed business decisions and have better conversations and negotiations with their provider network.

The shift to new reimbursement models does not have to be contentious and can benefit all stakeholders. We’ve worked with several clients to transition to new arrangements where they can realize the cost savings while also still doing right by their providers.

Looking for an Internship? Three Steps You Can Take to Stand Out

People can work remotely from nearly anywhere in the world today, creating a broad market for internships and giving businesses a large, diverse pool of young bright minds to hire. With more options comes increased competition. In today’s market, how can internship candidates make an impression?

  1. Good Communication

For an intern, one of the most important abilities to display to a potential employer is good communication. This may seem difficult when applying to a remote position, but luckily there are many ways to communicate that do not require being in the same room. Business forward social media such as LinkedIn allow people to connect and keep up with company news and updates. Before you even get to your interview, you can utilize LinkedIn by following the HealthEdge page and connecting with employees at the company.

  1. Enthusiasm

Many people believe the most critical quality for a candidate is experience. For an intern, that is not the E word employers are necessarily looking for. “We don’t expect anyone to have a lot of experience coming in; we’re not looking necessarily for prior internships,” says Kelly Finn, Manager of Talent Attraction at HealthEdge.

The best trait you can put forward in your interviews is enthusiasm. “The things that we specifically look for are: are they inquisitive? Do they want to learn? Do they have good questions?” Finn says.

According to HealthEdge Vice President of Talent Attraction, Katie Conti, the best traits you can display in your interview are curiosity, motivation and friendliness. “I’ll tell my team, half-jokingly, ‘Don’t bring any jerks in.’ Bring in nice people who are interested in being here, who are going to be enthusiastic and eager to learn,” she says.

  1. Research

The next step is proving you’ve done your research. An informed, engaged, and confident applicant stands out among the rest when all other aspects of a candidate are evenly matched.

When asked where to begin the research process, Finn suggested starting with the website, “just poke around the different pages so you can get a sense for what the company does.”

“We don’t expect you to be able to sell the company…but we do expect that you’ve looked at the website and understand generally what we do,” says Conti. Interviews are not meant to be a quiz but knowing this information can only help you come across as more confident and serious about the potential role.

Knowing enough that you can engage in the conversation, rather than just asking questions from a prepared list, is also one way to stand out because it proves you’re curious and informed. Let your questions come from the conversation and your interviewer will be impressed. You want to make sure they can tell you don’t want a job; you want their job.

For HealthEdge, ensuring your values align with the company’s is incredibly important. Excellence, collaboration, continuous improvement, innovation, and diversity are part of the core principles at HealthEdge, and if those are things you see yourself feeling at home with, I urge you to apply. I always knew I wanted an internship before entering the “real” workforce, but I wanted to be able to make my contribution this summer matter—a place where I could make a difference, and HealthEdge gave that to me.

Understanding the Complexity of Healthcare Costs

In a recent survey of 222 health plan executives, when asked, “how do you think COVID-19 will impact health insurance premiums?” 29% said lower, and 25% said stay the same. However, when asked the same question to 3,000 consumers, only 5% said lower, while 67% said premiums will increase. This is just one example from the survey that shows how hyper-focused consumers are on cost. In addition, consumers also said the costs have the greatest negative impact on their satisfaction with their health plan.

However, there are many components to healthcare costs, but those outside the industry may not always understand the complexities. Sometimes, even those of us within the industry have difficulty understanding and explaining all the complexities! Many responses to the consumer survey, not surprisingly, related to a lack of understanding of costs and blaming health insurers for the high costs.

As most consumers have seen on “explanations of benefits,” there are always “billed charges,” and several “discounts” or “allowed amounts.” Recently, a colleague had a medical procedure that was fairly expensive at $233,000 in “billed charges.” However, other than the office visit co-pays, this colleague paid nothing else – as everything was covered by insurance.

Billed charges originate with the provider of the care. From there, there are complex schedules that dictate what can be charged, based on the type of insurance. Sometimes, the consumer-paid insurance premiums help cover that cost. Sometimes, our taxes help cover that cost – for Medicare and Medicaid. It’s often the insurance company policies and sometimes State or Federal regulations that ensure that consumers don’t pay those high fees. The proposed Federal No Surprises Act is intended to help clear up some of this confusion. In all cases, the providers of the care also must pay the doctors, nurses, and other members of the care team. Those charges can help providers break even, sometimes make a profit, and sometimes a loss.

Pricing within the industry is confusing – leading to consumer dissatisfaction and mistrust. “Billed charges” can be compared to hotel “rack rates” – no one ever pays them – there is always some sort of discount. In the case of health insurance, all types of insurance (e.g., Employer-based, Individual, Exchange/Marketplace, Medicare, Medicaid) will cover some or all of these costs.

Patients want lower costs. While it varies by type of insurance, both insurance payers and providers of care are constantly looking for ways to lower costs while still recovering their expenses and making sure their overhead is covered.

Healthcare costs and transactions are complicated. Health plans need technology that enables them to be flexible, agile and provides real-time data sharing and transparency with the ability to make changes quickly. Improving operational efficiency, automation, and accuracy, with a system such as HealthRules, are key factors that can help payers and providers reduce administrative expenses and ultimately lower overall healthcare costs.