Month: February 2024

Top 5 Challenges Facing Health Plan Leaders in 2024

Posted on by HealthEdge

As the healthcare industry continues to evolve rapidly, health plan leaders face many challenges ranging from changing payment models to business automation. In a recent HealthEdge Annual Payer Market Report, insights were gathered from over 350 health plan leaders and executives, representing health plans of all shapes and sizes across the United States.

Health Plan Challenges Overview

Throughout the survey, modernizing technology and aligning IT with business objectives emerged as common themes and top challenges.  These challenges stem from the unprecedented pressures that payers are facing from every corner of the industry.  Some of these pressures include:

  • Rapidly evolving and ever-changing regulatory requirements
  • New market entrants setting new standards for consumer-friendly experiences
  • Clinical workforce shortages and staff burnout
  • Changing payment models and the rise of value-based care
  • Record-high healthcare costs
  • Consumer buying behaviors influenced by retail experiences

Ranked in order of importance, the five biggest challenges for health plan leaders are:

  1. Aligning business and IT resources
  2. Workforce shortages/burnout
  3. Business growth
  4. Managing costs
  5. Member satisfaction

These findings may not be surprising to many, but the order in which these challenges arose this year was interesting. In previous studies, aligning business and IT resources ranked anywhere from third to fifth place, or even lower. However, as the industry experiences a surge in changes and rapid transformation, health plans are acknowledging the importance of adopting modern technology that can help their organizations be more agile and responsive to evolving market demands.

 

Embracing Modern Solutions

Let’s explore how modern, highly interoperable technology solutions can solve health plans’ biggest challenges in 2024.

  • Modern solutions can help health plans seamlessly align business and IT resources. These responsive systems require fewer dependencies on IT resources to adapt to the business needs.
  • Workforce shortages are widespread across many industries, particularly in the healthcare sector. The pandemic has exacerbated this issue, leading to nearly 1 in 5 healthcare workers quitting their jobs. Shortages of clinical specialists, such as care managers, and a lack of highly trained billing professionals are negatively impacting health plans and members’ access to quality care. Furthermore, inaccurate claims pricing and processing lead to costly downstream re-work, over or under payments on claims, and dissatisfaction among members and providers. With modern solutions that facilitate automation and interoperability, health plans can achieve more accurate pricing and editing of claims, as well as advanced automation of manual processes. This will alleviate many frustrations that team members face in their day-to-day work.
  • Health plan leaders are constantly focused on expanding their business, whether through membership growth, mergers and acquisitions, or introduction of new product lines. In today’s complex and highly competitive environment, this is no easy lift. According to the report, payers’ biggest obstacle when it comes to expanding their membership is being able to offer a variety of plans that meet their members’ needs. The ability to swiftly create new offerings and adapt to changing market conditions is now possible with modern core administrative processing systems. Additionally, these systems offer greater access to real-time data and insights into the potential impact of business decisions, such as new products, populations, or regulations. Real-time data allows payers to identify new opportunities more precisely and gain competitive advantages for growth.
  • Managing costs has been a persistent challenge in the healthcare insurance industry. With the rise of complex payment models, new competitors, and evolving regulations, payers should consider leveraging advanced systems, such as core administrative processing systems (CAPS), care management solutions, payment integrity platforms, and member experience applications. These solutions enable the automation of business processes, reduction of overall cost per claim, increased nurse panel sizes, and smarter business decisions with greater visibility.
  • Improving member satisfaction is becoming more difficult, especially as modern healthcare consumers’ expectations are influenced by personalized and meaningful retail experiences. Member satisfaction is crucial, especially for Medicare Advantage plans, as CMS doubles the weight of member satisfaction in its Star ratings program, effective this year. Modern digital care management platforms can offer deeper insights into member populations and improve care managers’ ability to reach more at-risk and rising-risk members.

The year ahead will bring new challenges for payers. Leaders who leverage modern solutions, such as the ones offered by HealthEdge, are better equipped to address these issues head-on. Download the HealthEdge Annual Payer Market Report to gain exclusive insights and discover actionable key takeaways. For a more personalized roadmap to success, explore HealthEdge solutions at www.healthedge.com.

Modernizing Healthcare Payers: Insights from the HealthEdge® Annual Payer Market Report

Posted on by HealthEdge

Each year, HealthEdge conducts an extensive nationwide survey of the healthcare payer market in the United States. This survey serves as a valuable compass for health plan leaders, providing insights into the industry’s evolving challenges and opportunities.

The latest HealthEdge Annual Payer Market Report presents a fascinating picture of how technology is both the biggest challenge and the greatest ally for health plan leaders in the coming years. Let’s dive into the key findings from this report, shedding light on the role of technology in the healthcare payer landscape.

The Audience

This year’s survey garnered responses from over 350 health plan leaders and executives, representing diverse functional areas of the business and encompassing all types and sizes of health plans. Their collective insights offer a comprehensive view of the healthcare payer market.

The Dominant Themes

Throughout the survey, several dominant themes emerged, illustrating the impact of technology on the healthcare payer industry. These themes directly reflect the mounting pressures that payers are experiencing from multiple angles:

Evolving Regulatory Landscape:

Regulatory requirements are evolving at an unprecedented pace, aiming to address long-standing industry challenges such as cost, transparency, and value. Payers are required to adapt to these transformative regulations swiftly. To do so effectively, they must establish flexible and open technology systems.

Consumer Demand for Personalization:

Healthcare consumers today demand more personalized engagement and greater transparency, influenced by their modern retail experiences. Health plans must incorporate omnichannel communication capabilities to meet these consumer expectations.

Emerging Non-traditional Competitors:

Innovative, non-traditional competitors with tech-forward strategies continue to emerge, placing pressure on payers to excel in new member acquisition and member/provider satisfaction. System agility and high interoperability provide payers with a competitive advantage in this ever-changing landscape.

Workforce Challenges:

Workforce shortages and high turnover rates compel payers to automate their business processes further, empowering their current staff to achieve more with less. Modern solutions facilitate ease of use and higher levels of automation, ultimately reducing dependencies on manual resources.

Growing Complexity in Payment Models:

Changing payment models, such as value-based care and risk-sharing arrangements, contribute to the growing complexity of claims processing, performance measures, and plan configurations. Modern technology is pivotal in navigating these complexities efficiently.

Cost Management:

Managing costs has consistently been a top challenge for health plan leaders; this year is no exception. As business complexities increase, so do administrative costs. Leaders are focusing on strategies such as improving the financial accuracy of claims and increasing auto-adjudication rates to minimize costs.

Three Key Findings

  1. A notable 62% of health plan leaders consider investing in modern technology for digital transformation as the number one way to achieve organizational goals in the new year.
  2. Increasing interoperability across the healthcare ecosystem stands out as a promising strategy to reduce administrative costs, emphasizing the importance of seamless data sharing and efficient workflows.
  3. Achieving alignment between IT and business ranks as the most significant challenge for health plan leaders, necessitating the adoption of modern solutions that support business agility. Other top challenges include:
    • Addressing workforce shortages and burnout
    • Facilitating business growth through membership growth, acquisitions, and market expansion
    • Managing costs by improving the financial accuracy of claims and increasing auto-adjudication rates to reduce administrative expenses
    • Improving member satisfaction by providing personalized communication capabilities in a landscape of expanding consumer choices
    • Ensuring provider satisfaction through stronger payer-provider collaboration to successfully implement value-based care models

The Changing Role of Technology in the Healthcare Payer Market

Given the growing complexities and the industry-wide shift towards digital transformation, it comes as no surprise that health plan leaders unanimously agree on the pivotal role of modern technology in addressing their major challenges in the new year.

As leaders search for new technology solutions, the survey highlights the top criteria for evaluating and finding the right solution, listed in order of importance:

Modern technology capabilities:

Modern technology can better support the future needs of organizations, enabling payers to be flexible and agile and do more with fewer resources as the market evolves.

Access to real-time data and analytics:

Health plan leaders need seamless access to up-to-the-minute information through robust APIs. Real-time data and analytics empower them to adopt value-based care payment models confidently, strengthen member-provider relations, and meet regulatory requirements.

Ease of doing business and customer service:

Modern technology companies should demonstrate flexibility in their product offerings, contracting processes, and support services to truly become partners rather than just vendors, enhancing the ease of doing business and elevating customer service to new heights.

Hassle-free configuration, upgrades, and implementation:

Every payer organization has its unique digital transformation journey, business processes, and growth plans. Modern technology platforms offer greater flexibility and faster deployment of new features, making it easier for payers to adopt innovations. This ensures that the system can accommodate each payer’s unique configuration requirements.

Automation and efficiency:

Vendors should be able to demonstrate how their technology can facilitate end-to-end process automation. Operational efficiency becomes even more crucial as payers’ requirements continue to rise.

Looking Ahead in the Healthcare Payer Market

The HealthEdge Annual Payer Market Report clearly shows the healthcare payer industry’s transformation driven by technology. As the industry continues to evolve, payers recognize the critical need for flexible, responsive, and highly interoperable solutions to thrive in this dynamic and competitive market. Technology is not just an enabler; it is becoming a mission-critical growth driver for healthcare payers in the future.

Download the full HealthEdge Annual Payer Market Report to learn more about these findings and gain insights from industry leaders.