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With a track record of selling core/claims administration technology to health plans for more than 30 years, I’ve heard all the reasons as to why health plans want or need to convert from their legacy systems to something more modern. The key complaints typically include some or all of the following reasons: Lack of agility or trouble keeping up with change, high operating costs, quality/compliance issues, vendors ending product support, challenging to integrate, needing to consolidate, and/or unhappiness with current vendor support.

Any of these can be a viable reason to change core systems. However, leadership and organizations still often find themselves very disappointed with the change. In fact, our recent survey of 245 health plan IT executives found that 99% of respondents plan to evaluate their core administrative processing system in the next two years, even though 31% implemented the system less than four years ago.

The leaders may be experiencing unanticipated consequences of adding a solution to their organization holistically. Typically, they never looked at their “people, process and technology” together as part of their implementation. As a result, they find their operating/quality metrics are still down, customer satisfaction scores are suffering, they are out of compliance and management is unhappy.

What happened? Why is management again feeling the need to change course after buying a state-of-the-art system to solve their problems? These same execs will hear echoes of the same old complaints: “The new system does not work … it does not operate like our old system/service provider … we cannot get support from the vendor … we are losing key people.” Sound familiar?

With a bit of due diligence, we often find these same organizations are not leveraging major features and capabilities they already have in their systems. They simply took “the way they did things in the past” and implemented that into their new system. They never invested in quality training or change management, resulting in many of their workers being left unaware of new and important features. Furthermore, IT and business goals are not aligned. In our recent survey of 222 health plan executives, 38% said alignment between IT and the business is currently the top challenge facing their organization.

It is critical for health plans to take time at the beginning of the implementation process to properly look at their existing processes and then map out and train respective employees on the new processes in order to harness the power of technology. Frankly, some health plans would have been better off staying with their older legacy solutions or service than making the change without addressing their implementation more holistically!

I often advise clients upfront: “I can sell you the most advanced core administrative system in the industry; however, if you do not factor ‘people, process and technology’ into your implementation, you will fail.” This includes not only “the people” you want to implement your new system, but “the processes” needed to fully leverage your new system. We as a company have walked away from a few opportunities over the years because health plans were simply looking to replace their old systems with HealthRules Payer® without factoring in change management. For example, one plan admitted to me that while they wanted HealthRules Payer, they wanted the interface to look the same as their old system so they would not need to change the way they do business or train employees. While I understand the desire to save time early on, this is a recipe for failure and will be costly in the long run.

So, the bottom line is if you are truly going to change systems or technology, make sure you budget and consider “people, process and technology” together. Sometimes your core or clinical solutions vendor can help you, and other times, you may want to consider an outside services provider who can help you step back and objectively show you “best practices” at plans similar to yours. They can also help you build in the proper change management to leverage your new technology.

Tri Agencies published a Frequently Asked Questions (FAQ) document on August 20, 2021, addressing the Transparency in Coverage (TiC) Machine-Readable Files (MFRs) and much of the transparency and consumer protections in the Consolidated Appropriations Act (CAA). This signaled the intent to take a more methodical and intentional approach to the rulemaking and acknowledged that the components are more complex than first blush.

Machine-Readable Files (MFRs)

First, they looked at the requirement for all non-grandfathered plans to post three MFRs to their public website by January 1, 2022. They deferred enforcement for In-Network Rates and Allowed Amount files―the two categories that HealthEdge plays a part in―to July 1, 2022, for complete compliance. Regardless, we’re staying on schedule and developing the utilities in-process for these two files and are targeting a release date in Q4.

The Tri Agencies also delayed, until future rulemaking, the prescription drug machine-readable file requirement due to disparities between the various prescription drug rules.

Price Comparison Tool

The FAQ also impacts the CAA requirement for group health plans to make a Price Comparison Tool available online or by phone. The Tri-Agencies acknowledged that this requirement is essentially a duplicate of the TiC Online Shopping Tool, except that it adds the ability to access by telephone. To better align the shopping tools, the Tri Agencies delayed enforcement until January 2023.

Advanced Explanation of Benefits (A+EOB)

A+EOB will require the provider to send a good faith estimate of an upcoming service a member is scheduled to receive to the health plan. The plan will then process it, much as they would process any claim, except that it’s a trial claim―and that’s what HealthEdge is going to be enhancing.

The Tri Agencies cited the complexity of the development around the standards for the good faith estimate and the communication from provider to plan. They intend to issue a notice of proposed rulemaking along with a comment period. So, we will not see enforcement on January 1 of 2022, until the rulemaking process is complete.

HealthEdge is collaborating with clients and working through discovery and solutioning, and identifying enhancements we can make to our trial claim functionality to accommodate the A+EOB along with the Price Comparison Tool.

Interoperability and Transparency

Although not included in the FAQ, beginning on July 1, 2021, the Patient Access and Provider Directory APIs went into effect. HealthEdge published material on the patient access data mapping for the API. This data mapping can also be used for the payer-to-payer data exchange, which goes into effect on January 1, 2022. This rule will allow members to request up to five years of historical data to be digitally sent from their previous plan to their new plan. The patient access data mapping guide provides the data element mapping for the previous health plan to export and send to the new plan.

With a little breathing space from the more calculated implementation of the TiC and the CAA, I expect we will begin to look at ways the historical data will benefit new members; and quickly realize the value in using the historical data to look at the members’ current health stats, identify care gaps, and recommend treatment or preventive care.

Takeaways

With any compliance mandate, there is a good intention behind it, including the interoperability, transparency, and other consumer protections that we’ve seen come through rulemaking in the last couple of years.

These rules make the healthcare industry more member-centric, with the intent to reduce the overall cost of care by getting members involved in their decision-making. The digital movement of data will help facilitate these efforts; if members know what preventive services they should receive and understand their supplemental benefits, the outcomes should improve.

Our recent consumer survey showed that 47% of the 3,000 respondents postponed care. And of that 47%, 55% delayed routine visits, 39% elective treatment, 32% essential treatment of a chronic condition and 22% emergency care. This might be slightly elevated because of the fear factor related to COVID-19, but many people may not be aware that consumers postpone care all the time. Many times, it’s because of the desire to avoid high costs.

So, it’s no surprise that when asked what services would improve the consumers’ current level of satisfaction with their health plan, tools or information to help understand benefits and financial responsibility (55%) and to help find less costly care (49%) topped the list.  Confusion continues beyond just transactions and expenses; the consumer survey also found that 50% of insured American adults don’t know all the services covered under their health plan.

Value-Based Reimbursement Collaboration is Essential for Keeping Members Healthy and Lowering costs

Confusion around health insurance costs and coverage leading to delayed care is critical for payers to address because healthcare is changing, and the focus is shifting to quality. As the industry moves to value-based reimbursements, members avoiding care can actually drive costs up. Many regulations are requiring evidence of quality in the hospitals, health plans and clinics, etc. As a result, providers can be rewarded financially for demonstrating quality and keeping patients healthy. The benefit to payors is, if members are kept healthy, costs for everyone can decrease, and member satisfaction can increase.

For a high-risk Medicare member, a health plan might receive several thousand monthly reimbursements from CMS to care for that member. If the member gets sick, the cost of care chips away at that reimbursement. If the health plan and the provider work together and keep that member healthy, everyone benefits, including from a financial perspective. Preventative care and proactive treatment to keep members healthy benefits everyone in the healthcare ecosystem.

The Communication Gap in Preventive Care

Despite the benefits of Value-Based Reimbursement Collaboration, there is still a communication gap when it comes to supporting and promoting preventive care.

According to the consumer survey, when asked if a health insurance company, primary care physician, or a specialist directed the consumer to a community resource like Meals on Wheels or housing assistance to further support their care, 72% said no, including 83% of Medicare Advantage members and 77% of Medicare members.

“There is a significant communication gap and missed opportunity for the most vulnerable populations to take advantage of the resources available to help improve their care and overall well-being. There is also evidence that consumers will use these resources if they know they exist. For those directed to community resources, 81% engaged with the services—up from 57% in 2019.”

Consumers want tools to understand their costs, benefits covered, community resources, and overall better communication; if payers and providers work together to improve outreach and overall transparency, it will keep members healthy, lower costs, and benefit everyone in the long run.

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.

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.