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California Advancing & Innovation Medi-Cal Enhanced Care Management (CalAIM) is designed to improve the level of whole person care that is given to the population. This is especially true for members that need additional help and non-traditional services in order to be able to attend to their physical health and wellbeing. This includes individuals who don’t have housing, transportation, and/or need assistance with getting meals to live a healthy lifestyle.

How can care management platforms support these vulnerable members with complex needs and be compliant with CalAIM?

A member-centric approach is key – where the care management platform coordinates all the pieces of their healthcare, including care management, utilization management, and access to healthcare services and support. With this, it is imperative that each member has a comprehensive care plan that includes all facets of their health, and their providers can access that plan and collaborate on it.

What should you be looking for in a care management platform to meet CalAIM’s requirements and support vulnerable populations?

1. Evidence-based Assessments for Diverse Population Needs

Safety net populations represent a complex and diverse set of members and healthcare needs. To support them, care management platforms need to provide a comprehensive, customizable set of evidence-based assessments and the ability to centrally manage care from one application for all healthcare needs/providers.

2. Utilization Tracking & Budget Management

Members with complex needs, especially when part of a population with challenging circumstances, need to clearly and easily understand what services they truly need, what their benefits are, and how to access those services.

It’s critical that the care management platform can:

• Assess their healthcare & support services needs
• Understand their benefits

With this information, the care management platform can drive their plan of care, which can also drive their need for some of the enhanced care management services.

3. Mobile Application

A comprehensive care management platform with a mobile application empowers the care team to meet the member where they are and still be able to assess them in offline mode. Care is no longer dependent on a member’s transportation or won’t be interrupted because of lack of internet access.

One of the biggest challenges CalAIM is facing is reaching and supporting the homeless population. Care management platforms that are mobile and don’t rely on the internet enable care providers to support these members.

 GuidingCare and Whole Person Care

GuidingCare care management platform was purpose built to be able to serve the most complex and vulnerable populations. From the start, GuidingCare’s member-centric approach has been focused on coordinating all aspects of member’s care. GuidingCare offers over 260 evidence-based assessments that drive care plans and can be configured to meet specific state and population requirements. Learn more here.

 

Healthcare organizations and leaders are thinking about how to provide the experiences that patients and consumers have come to expect from the healthcare system. However, the legacy technology platforms that many organizations have today–especially payers– often disrupt digital transformation.

In a recent episode of The Healthcare Solutions Project podcast, Sagnik Battacharya, EVP at HealthEdge, talks about how payers can accomplish true business transformation, both in terms of data capabilities and interoperability, and the reasons why they should.

Incentives to Drive Interoperability

Provider-to-provider interoperability has taken significant strides forward in the last decade, but interoperability between payers and between payers and providers isn’t yet at the same level. EHR vendors have done a good job of integrating disparate systems, showing that there is a real opportunity for tighter integration and interoperability between existing payer systems.

Incentives and rules being put in place by the government, such as the 21^st Century Cures Act, are now being implemented through various rules published by CMS and are driving a focus on interoperability, especially for payers.

The key to interoperability goes beyond having the correct tools, such as APIs, FIHR, and CCDs. These capabilities don’t matter if the information is not available to the right person when and where they need it and in a format that is easily digestible. Oftentimes, providers are getting too much information to sort through in the limited time that they have. When interoperability is executed correctly, the technical capabilities seemingly fade into the background and the result is patients and providers have the information they need at their fingertips.

Digital Transformation Requires Both Technology and Mindset

Businesses run on technology – but that technology is not always created equal. Businesses need to ask themselves if the platforms and technology they are using are allowing them to move their business at the pace that they want. While every business transformation takes time, if technology is your rate-limiting step, then you would be hard-pressed to call yourself a digital business.

But digital transformation requires more than just having the appropriate technology infrastructure. Sagnik Battacharaya emphasizes that it requires “a mindset that allows an organization to move at the pace of consumer expectations over the next ten years,” and points to digital companies like Amazon, Apple and Google as examples of companies that healthcare businesses can learn from.

These digital companies are incredibly end-user-focused. They have a high degree of quality and incredibly high service levels, but providing amazing member experiences is not enough. If you want to be truly digital, you also need to be agile enough to know what consumers are going to expect 10 years from now.

What’s Driving Businesses Toward a Digital Transformation?

The areas of growth within the health insurance markets today are centered around Medicare Advantage, Medicaid and healthcare exchanges. Compared to employer-provided plans, individuals have more choices available to them when selecting one of these options. Numerous plans could be competing for their attention through services or the experiences they provide resulting in individuals who are selecting plans not only based on the premiums but on the services and digital experiences they desire.

Benefits of Digital Transformation

According to a recent survey of HealthEdge customer executives, their highest strategic priority over the next couple of years is operation efficiency. They want to take better care of their members, and one way they can do this is by increasing efficiency – resulting in less spending. These savings can then be passed onto their members.

Weaknesses within legacy systems include the inability to be agile and make business transformations faster and easier. Sagnik discusses how customers leveraging digital technology from HealthEdge during the Covid outbreak were able to very rapidly make changes to comply with the new rules that CMS was pushing out. He states “because we had built this really configurable system that put control in the hands of the business users and the clinical users, they were able to make those changes in less than a week…”

A digital transformation could help an organization improve other key business metrics as well. Member loyalty and retention is increasingly important as individuals are given more choices. According to Sagnik, one member health plan has seen 99% member retention because they have successfully engaged with their members digitally.

Another metric closely monitored by health plans are auto adjudication rates. HealthEdge regularly sees their clients who are able to attain over 90% auto adjudication rates, which would be pretty difficult to accomplish with legacy systems.

Learn more about becoming a digital payer here.

 

We are nearing the 1/1/23 requirement for health plans to provide online shopping/price comparison on health plan member portals for around 500 services. This is part of the Transparency in Coverage Rule.

Members will be able to sign into their health plan member portal with their credentials – select a provider, select one of 500 services/procedures, and get back a personalized view of the cost that factors in their cost sharing and negotiated rate elements. With this, members get a clear understanding of what a service will cost with that provider. With this personalized view, members can make an educated decision about the cost of their healthcare services & procedures.

How is this different?

Health plans currently have a pricing tool that shows basic prices – such as an office visit, cardiologist visit, or echocardiogram. However, it’s not personalized. With this new requirement, members will have full transparency. They will understand what the cost for the service will be based on their specific benefit plan, which providers are in network, and where they’re at in their particular plan (deductible, max out of pocket).

Which plans are included?

All commercial plans must meet this requirement. This includes all individual and family plans on/off the exchange. This does not apply to Medicare or Medicaid.

What does this mean?

This is an exciting step forward toward healthcare becoming more digital and patient-centric. It also aligns with the soon-to-come Advanced Explanation of Benefits.

For example, say you have a knee injury and need replacement surgery. As of 1/1/23, with the Transparency in Coverage requirements, you’ll be able to log into your health plan portal and compare prices for that procedure. A broader scope of shoppable services must be made available to you in 2024.The Advanced EOB will be the next generation of this service. With the Advanced EOB your physician would request one from your health plan with the specific codes for that knee surgery. This Advanced EOB tells you, if you have this service with this provider and everything matches, this would be your benefit. It’s like getting your EOB before you even decide to have the surgery. Versus today, where you get the knee surgery and then some time after you get your EOB, and know your cost share.

Pricing Transparency & HealthEdge – The Wave toward Digital

HealthEdge is on the forefront of pricing transparency and enabling health plans to empower members to make educated decisions about their health. HealthEdge has had tools in place for several years to consume the items and services and based on the member and provider return personalized cost sharing information.  HealthEdge’s suite of products provide accurate real-time data – the backbone of pricing transparency. Learn more here.

Have you ever tried to find an in-network doctor on your health plan member portal, found one, and called them – only to find out that they’re not actually in network? Or worse, gone to a doctor you thought was in network only to later get a bill and find out they weren’t in network?

This common, frustrating problem is on CMS’ radar and could affect CMS regulations down the road. In CMS’ ongoing work to support interoperability & prior authorization, increase access to care, and decrease clinical burden/provider abrasion – they have their sights set on establishing the first, national directory of health care providers and services.

What’s the challenge?

Currently, there is no central directory for providers and services. This fragmented system makes it challenging for patients to find up-to-date information on providers and to find providers who are in network. It’s also challenging for providers – who have to update multiple databases and follow the requirements for each database.

It’s cumbersome and tiresome to both patients and providers. This barrier to care negatively impacts healthcare, as easy to find, accurate provider and service information is critical to member and population health.

The future – an accurate directory of providers  

CMS is considering developing a directory that would be a ‘centralized data hub’ for all health care. This ‘National Directory of Healthcare Providers & Services’ (NDH) would include accurate data in a publicly accessible database, developed through streamlined information submission from providers.

What you need to know

CMS has released a Request for Information (RFI) seeking public feedback on the NDH concept. CMS wants to know if consolidating this data in a central repository would improve access to care and make it easier for patients to find, evaluate, and compare providers based on their unique needs – such as accessibility and languages spoken.

How to provide your feedback

CMS is seeking feedback to better understand current health care directories and information they should consider as they develop the NDH concept. CMS is particularly looking for public feedback on benefits, provider types, entities, data elements, priorities, and any potential risks and challenges.

The CMS RFI is open for 60 days. It ends December 6, 2022.

Learn more and submit your feedback on the NDH here: https://www.cms.gov/newsroom/press-releases/cms-asks-public-input-establishing-first-national-directory-health-care-providers-and-services

Cybersecurity is a constantly evolving threat with the potential for massive risk and impact. HealthEdge is always on guard against cyber threats with a security blueprint and technology stack. The main HealthEdge cybersecurity pillars are:

1. Prevention

Prevention is a critical component of cybersecurity. HealthEdge secures the network infrastructure with segmentation and network traffic controls. We commit to continuous vulnerability and patch management, as well as security for incoming and outgoing data management with data loss prevention controls, Internet proxies for secure browsing, and email security controls to protect users from malicious attachments, links, and phishing. Endpoint devices are secured on and off the network, including mobile devices to ensure secure collaboration and sharing. HealthEdge ensures our team is regularly trained on information security through our robust Security Awareness For Everyone (SAFE) program. Targeted training is conducted for secure coding, which ensures security by design.

2. Access Control

Identity and access management controls allow authorized user access to the corporate network. Security controls are configured for remote access using VPN and multi-factor authentication.

3. Operations Management

Security Operations and Compliance work in tandem to monitor and enforce policy for cloud-based applications. Security data from across the environment is ingested and normalized into our Security Information and Event Management (SIEM) tool in real-time. Using the correlated data, the Security Operations team can quickly respond to security events using our Security Orchestration Automation Response (SOAR) tool.

4. Securing Applications & Validating Controls

HealthEdge continuously tests our website, and applications for code vulnerabilities. We protect web applications from malicious attackers using our Web Application Firewall (WAF) and monitor third-party risk using public information to profile a company’s security behavior. These controls are validated through governance risk and compliance with penetration testing and continuous auditing to ensure the company is meeting compliance and risk standards.

5. Intelligence

In addition to security controls managed internally, HealthEdge has a robust threat intelligence program through partnerships with healthcare industry peers and cybersecurity experts. Alerts and reports are continuously assessed, and security controls are regularly adjusted in accordance with intelligence findings and applicability.

6. Response

Because the threat is always evolving, HealthEdge must be positioned to immediately respond to security incidents.  This response is a coordinated effort in which we collect data and correlate behavior to achieve comprehensive understanding during the investigation process. eDiscovery ensures data is collected, and integrity is maintained, for legal matters. Response strategies include Business Continuity Planning (BCP), Disaster Recovery (DR), and controls to support redundancy and availability, which are regularly evaluated for improvements.

HealthEdge understands what it means to be a good steward of customer data and we take this responsibility seriously. Our teams work around the clock to ensure maturity when it comes to pillars of security. Follow us next month when we dive into industry trends and top threats.

Is it possible?  Can competitors also collaborate?  Do they already?  When is it acceptable?  When does it push reasonable boundaries and when does it cross the line?  This post will cover those thoughts and others surrounding the value of ‘collaborative competition’.

In a recent in-person discussion with multiple customers, some competing for market share within the same geographic region, we were told, admonished really, that we (the ‘vendor partner’) worry more about their competition than they do – and they would find value and appreciate the opportunity to collaborate more.

I’ve been in the health plan business since 1990 and reflecting on the 90s when managed Medicare was beginning to grow, then regulated by the Health Care Financing Administration (HCFA), a predecessor to CMS, fierce competition quickly followed.  Health plans offering Medicare coverage within the same geographic region became strong competitors.  At the time, competition was based on the variety of benefits offered, co-pays and co-insurance, and most apparent, the premiums.

Very shortly afterwards, premiums dropped dramatically, and zero premium plans surfaced and became commonplace.  No longer was competition based on premium – shifting to benefits and member/beneficiary out-of-pocket cost.  This has remained a competitive factor for the past almost 30 years, and in more recent history, individualized customer care/service, predictability of cost, and quality (effectively, “The Triple Aim”), sometimes now Quadruple or Quintuple (often adding staff satisfaction and equity).

Competition in the markets of Medicare as well as Medicaid and Commercial remain a focus for health plans today.  This was confirmed earlier in 2022 when HealthEdge commissioned an independent study of over 300 health insurance executives on a variety of topics.  Competitive pressure was selected as a top challenge by 35% of executives responding, ranking fifth.  Competition also showed up regarding member acquisition, with 23% of respondents listing this as a top concern.  However, when reviewing the responses regarding technology, competition did not appear in the results.  Instead, investments in technology and alignment of business and IT were consistently the top two technology goals – with 53% of executives confirming.  An opportunity for collaboration exists here.

All health plans must efficiently operationalize in essentially the same manner – and utilize similar internal processes.  Some developing processes, for example, the approach to handling value-based care, remain competitive.  During the past couple decades, competition has increased within the health plan marketing environment – with various marketing solutions offering competitive advantages for capturing increased market share.  Typically, marketing is managed separately from the core operations within a health plan.  Does this make operational collaboration more reasonable?  Many would say yes.

Take provider data as an example.  It’s not unreasonable to conclude that 100% of health plans have some challenges in managing their provider data.  Health plans within the same geographic region often have very labor-intensive processes surrounding activities such as credentialing.  Some geographic regions, even some entire States, have established a variety of credential verification services – a “one-stop-shopping” approach, per se, to ease credentialing for everyone.  This is a collaborative solution that benefits everyone in the region yet does nothing to inhibit competition.

Often, health plans have built-in trust issues with their software vendors.  Time and effort are required to establish an effective partnership based on mutual understanding and common goals.  While this trust and partnership is being established and built, health plans can find common ground with one another.  As with any challenge in life, we all know that we’re rarely the first to experience something – and the collective experience of others can help to address any challenge.  Customers with common solutions can share experiences, tips and tricks, hacks.  And we all know everyone hates to open a ticket.  How nice to address an issue without that.  Do you contact Apple® support for questions regarding your iPhone®?  More than likely, you find the nearest teenager!  Health plans, even competitive ones, can commiserate, communicate, and collaborate as they have the same challenges.  There is strength in numbers – solving a challenge together is more effective that going it alone.  Networking with others within our small world also has many unintentional benefits.

My answers to the initial questions posed…  Is it possible to collaborate in a competitive marketplace?  Yes, it is possible!  Yes, competitors can also collaborate (sometimes)!  And yes, some already are!  When is it acceptable?  More often than some think!  When does it push the reasonable boundaries and/or cross the line?  When using similar solutions, far less frequently and rarely crosses any inappropriate lines.

A way to begin to establish new collaborative relationships is also through customer user groups.  If you’re not already connected to your HealthEdge product user group, use this link to register for the user groups of your choice.  If you are already a HealthEdge customer, feel free to also contact your HealthEdge Account Executive who can guide you as needed.  Go forth and collaborate!