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Health plans must add or expand new business models quickly to take advantage of opportunities, drive competitive advantage, and retain membership. All health plans, no matter the size, continually address their business plans by expanding into new geographical markets, creating new products, marketing to new customers, or simply retaining membership by building satisfaction and loyalty. But to do it successfully, they must be able to answer the following questions before they launch:

• What benefit offerings will resonate with the market?
• How can the retention rate for existing business be improved?
• Will the group/member setup be completed on-time with high quality for processing?
• Does the provider community properly support improved health and low cost to the members?

In the years I’ve spent working directly with our customers, I’ve learned a lot about what they are worried about, what challenges they’re facing, and what keeps them up at night. While working with large regional health plans, here are some of the scenarios I’ve witnessed:

A regional Northeast health plan with Commercial, Self-Funded, Medicare Advantage, and Medicaid lines of business, added new provider contract and payment models, and implemented value-based payments, to align with the provider network. By doing this, they increased customer satisfaction and overall health in the community, as well as improved stakeholder engagement among members, employers, providers, and hospitals.

A Mid-West organization with Commercial, Individual, Medicare Advantage, and Medicaid lines of business, focused on speed-to-market and decreased time to create and launch a new benefit plan. As a result, they increased member satisfaction by simplifying account setup and enrollment and reducing errors.

Several customers have had to respond to providers and consumers embracing new care by offering patients a hybrid of telehealth and physical visits and enhanced mental health resources. With multiple options to deliver and receive quality, convenient care, it’s important that health plans design benefit plans that address consumers’ needs.

When all is said and done, I’ve come to realize that maintaining flexibility and the ability to respond quickly and correctly the first time not only enhances a payer’s competitive position but, in many cases, can save a regional plan. It has become binary. Have the ability and succeed, or not build the capability and fail. Happily, I’ve seen many chose to succeed.

The AHIP Institute and Expo went completely virtual this year. Health plan executives from across the country participated in panel discussions, browsed virtual exhibit halls, and connected in digital lounges. While topics covered a myriad of current issues in the healthcare industry, the impact of COVID-19 was front and center.

COVID-19 takes over

As millions have lost their jobs, resulting in jeopardizing their employer-sponsored health insurance, COVID-19 has highlighted the need for improved access to care and a healthcare safety net to ensure adequate coverage for everyone, especially during a pandemic.

The impact of sustained unemployment on health plans has yet to be fully realized. Employer health plans may be permanently changed as more employees seek care through the ACA marketplace instead of COBRA. Health plans across the board must consider ways to help members navigate the complex system and reevaluate their benefit design and programs to make healthcare more accessible overall.

Presenters also discussed health equity with an emphasis on prevention. Social determinants of health and disparities among more vulnerable populations must be scrutinized closely to achieve equitable care for all.

The pandemic has demonstrated how the private and public sectors can mobilize quickly and work together to spur innovation, provide necessary funding, and initiate community outreach. There is hope that these partnerships will continue in the post-COVID-19 world to create a better experience for patients, build trust, close gaps in care, and drive better outcomes.

Access to care must start at the local level and is moving in that direction already. Consumers are seeking a holistic approach to healthcare that is local, convenient, and easy to understand. In addition to states making healthcare more accessible, every aspect of the healthcare industry must work in harmony to identify solutions and provide seamless, meaningful care.

Increase in telehealth adoption leading a push for continued use in a post-pandemic world

With the rise of telemedicine, digital health solutions, and emerging technologies, COVID-19 completely transformed how patients connect with their providers. In the wake of COVID-19, government officials and health plans quickly expanded access to telehealth through relaxed regulations, waived fees, adapted reimbursement policies, and more. The pandemic has showcased the importance of staying connected and having alternative care solutions readily available.

Virtual care not only slowed the spread of coronavirus by keeping people out of waiting rooms, but it opened the door for safer, more convenient ways to deliver care. Now, nearly half of the physicians in the country are using telehealth.

In addition to increased adoption across the board—presenters confirmed more than 200 million telehealth visits during COVID-19 already—there has been an industry push for continued telehealth use in a post-pandemic world.

Congress added telemedicine as a basic benefit to Medicare Advantage and secured fee-for-service payment models for substance abuse treatment. Many policymakers are pushing for mental health coverage as well. Industry leaders hope that more states coordinate with each other and create continuous licensure to ensure consistent quality of care.

Health plans were able to quickly expand their virtual care services, at a time of unprecedented demand. Moving forward, payers are essential for making telehealth a regular part of medical care and should remain focused on curating offerings by benefit design.

To learn more, read our blog, Telehealth is here to stay, healthcare industry sees immense value in virtual care.

Data-sharing for better outcomes

The value of analytics within healthcare is ever-present and more important than ever, COVID-19 has emphasized the need for confidential information sharing.

Several topics at AHIP explored the use of data in value-based care and how greater interoperability and access to information will help the healthcare community achieve better care at a lower cost. Using data to deliver treatment when needed has proven to be cost-effective, efficient, and create better patient outcomes.

Value-based care programs encourage patient-centric care coordination that enables providers to view and share real-time data. Panelists agreed that sharing critical information will drive positive change and improve healthcare. However, many noted current challenges hinder payers and providers from developing improved care management models. Data standardization and access to information are key to ensuring care coordination is possible, but to promote interoperability, the industry needs common standards.

Healthcare must move away from siloed systems and operate in a common ecosystem that drives value, equity, and access. Providers and payers must work together to align incentives and create more extensive value-based arrangements. Patient-centric care management will lead to improved patient satisfaction and healthier communities.

HealthEdge customers have the flexibility to address ongoing changes as healthcare evolves. We will continue to track key developments, their potential impacts on the healthcare environment, and work closely with health plans to adapt, create new opportunities, and improve care.

Not able to at this year’s Institute? We’ve got you covered! You can visit our AHIP Silver Sponsor Booth through December 1, 2020.

Schedule a 15-minute introductory call to discuss your business opportunities and challenges.

For more information, call: 781.285.1300 and ask to speak to Janet Barros.

The COVID-19 pandemic forced the healthcare industry to adapt quickly, embrace change, and accelerate the adoption of telehealth practices for a variety of services.

Providers have reported that telehealth visits have increased 50 to 175 times during the pandemic, and Forrester Research anticipates that virtual appointments in the U.S. will exceed 1 billion in 2020.

Telehealth adoption will likely continue to increase as more payers, providers, and patients realize the immense value of virtual care quality and convenience.

Benefits of Telehealth

Telehealth removes barriers and enhances access to care in areas that typically experience shortages, such as behavioral health. As Fierce Healthcare notes, “One in five adults in the U.S. has a clinically significant mental health or substance use disorder, yet many people do not receive treatment for their problems because of a shortage of mental health providers and lack of access to mental health services.”

And, in the time of a global pandemic, access to mental health services is more critical than ever. From healthcare workers, caretakers, to those dealing with job loss and isolation, the mental health impacts of COVID-19 are varied and far-reaching. A Teledoc Health survey found that 47% of the 1,001 respondents experienced a negative effect on their mental health during the pandemic. Further, virtual mental health appointments for patients between 18-30 doubled between March and April 2020.

Industry experts agree that the long-term sustainability of behavioral health integration requires enhanced technologies. Moving forward, telehealth will continue to play a vital role in providing easier, more convenient access to mental health options and services when patients need it most.

Telehealth enables the delivery of care without in-person contact. For many people, especially at-risk and elderly populations, virtual appointments are the most effective and safest way to get answers to their health care needs and access prescription refills and other services.

The flexibility CMS offered to providers to obtain Medicare reimbursement for telehealth during the pandemic caused a surge in telehealth visits. According to Medicare claims data, with 1.3 million members receiving virtual care in the week ending April 18, telehealth services increased more than 11,718% in just six weeks.

While CMS set these current waivers to expire when the public health emergency passes, many lobbying, and industry groups are requesting that CMS extend until the end of 2021. As more groups call for HHS to permanently relax certain restrictions, top health officials are open to exploring possibilities; if this happens, we will continue to see telehealth take on a larger share of the healthcare market.

What it means for payers

COVID-19 demonstrated the need for telehealth and unlocked endless benefits. In just a few short months, health plans across the country have invested in and expanded their telehealth offerings.

Healthcare Finance reported that telehealth-related claims for privately insured populations increased 4,347% nationally from March 2019 to March 2020, and McKinsey predicts that telehealth could account for up to 20% of all Medicare, Medicaid, and commercial outpatient, office, and home health spend. Furthermore, more than 75% of consumers say they are likely to use telehealth in the future, demonstrating that telehealth is here to stay.

Telehealth supports and enhances the ways consumers can receive high-quality care. Payers should seize this opportunity to modernize their offerings. To remain competitive, health plans must respond to this industry trend, build telehealth into their products and payment models, and create awareness around telehealth offerings to drive growth and close the gap between interest and usage.

According to McKinsey, “Health plans should look to optimize provider networks and accelerate value-based contracting to incentivize telehealth. Align incentives for using telehealth, particularly for chronic patients, with the shift to risk-based payment models.”

The flexibility of HealthEdge’s solutions helps payers stay competitive and respond quickly to changing market dynamics like the increased adoption of telehealth. With HealthEdge, our customers can easily configure new lines of business and payment models, stay focused on innovation, and keep their members healthy.

At HealthEdge, the voice of our customers drives our innovation. Listening to our customers’ needs allows us to accelerate the delivery of valuable features and proactively remove barriers to their success.

Today, some health plans run on decades-old systems built on legacy technologies that do not lend themselves to innovation or shifting market dynamics. The reality is that the healthcare industry is constantly evolving. Health plans need a system that can keep up with rapid change and meets their business requirements as this experience with COVID-19 has shown.

HealthEdge’s solutions are based on modern technologies, modern tools, and modern development and deployment processes.

We actively look for customer input through a variety of channels. HealthEdge frequently participates in monthly user group meetings hosted by our customers, an annual customer conference, and numerous one-to-one user research visits by the Product Management and UX teams. Further, the Product Management team gathers feedback from the Support team, the Professional Services team’s experience during implementations, and gains insights from our account managers, who spend significant time with our customers in the field.

With product and market feedback in-hand, HealthEdge utilizes the Agile and Scrum software development processes, which focus on frequent delivery of working software. This methodology allows us to be extremely responsive to our customers’ requests, evolving marketing trends, or to modify products for compliance mandates.

This constant innovation enables us to ship Generally Available (GA) software releases many times per year, at no additional cost. These regular updates provide new capabilities that allow health insurers to stay current and competitive with the latest industry developments and pivot whenever needed.

HealthEdge’s approach to innovation is unique in the health insurance arena. As Vice President of Product Management, we guide our product, development, and operational teams to help modernize our industry in a way that is similar to other technology segments, where new business value and automation are delivered routinely. Our continued partnership with our customers will help us transform the way this industry operates, bringing more value and efficiency to payers and the members they serve.

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This edition of ‘the Edge Report is authored by Scott Sbihli, Vice President of Product Management. Scott is an experienced business and technology leader with a record of accomplishment in building and managing innovation, product, and business teams. Scott is originally from Michigan and now calls the greater Boston area home.

In the wake of the COVID-19, health plans across the country have had to respond to a multitude of ongoing changes in a short amount of time. Here are some examples of how payers are making adjustments, working with their customers, and keeping their organizations running smoothly.

Keeping members and community healthy tops health plans’ concerns during COVID-19

 Health plans’ concerns extend far beyond operational aspects; first and foremost, health plans want to ensure they are taking care of members from a health and financial perspective during this challenging time.

In a joint letter, Humana President and CEO Bruce Broussard and Cigna President and CEO David Cordani stated, “no patient should have to worry about treatment costs in a time of crisis. We are doing all that we can to remove this uncertainty–not because it is the profitable thing to do–but because it is the right thing to do.”

They, along with several other health plans, have expanded access to care through additional open enrollment periods for individuals, easing restrictions and costs for telehealth services, waiving fees for COVID-19 testing and treatment, providing early prescription refills, and much more.

In this unprecedented time, communication is key. Payers are focused on outreach and connecting members with resources and information.

Aetna’s care managers, for example, proactively reached out to high-risk members and walked them through how to protect themselves and where to get tested for COVID-19. And, members who are diagnosed and hospitalized with COVID-19 receive care packages from Aetna containing cleaning supplies, resources, and information.

Many health plans created support lines that members can call to get answers to their COVID-19 related questions and launched dedicated pages on their websites with regular COVID-19 news and updates, FAQs, and links to community resources, CDC information, and more.

Some health plans are expanding service offerings to address mental health and wellness. Health Partners Plans offers free online health and fitness classes for members, including dancing, yoga, Thai Chi, and cooking classes. And MedCost partnered with Carolina Behavioral Health Alliance and Mood Treatment Center to offer a free wellness webinar series on topics like managing anxiety, tips to better sleep, and sobriety, to help its members, and the public, find ways to cope during COVID-19.

Keeping up to date with regulations and implementing changes and new requirements

State and federal guidelines and regulations on COVID-19 are constantly changing, and health plans must keep track of the updates and adapt quickly to address new requirements.

Telemedicine experienced some of the most significant changes. Traditionally for primary care medicine, telemedicine has drastically expanded during COVID-19. With social distancing guidelines in place, almost all health plans have eased restrictions for telehealth services and are offering these services at no cost. For example, McLaren Northern Michigan Clinics quickly adapted their McLarenNow mobile app to extend the use and enable physicians, nurse practitioners, and physicians assistants to treat patients virtually.

Health plans are also aware that social distancing can cause feelings of isolation and potential for increases and substance use disorders and mental health struggles. Neighborhood Health Plan of Rhode Island waived requirements for providers seeking prior authorizations for all behavioral health and inpatient medical services, regardless of whether it is related to COVID-19.

Elevating care and giving back to their local communities.

In this time of crisis, health plans are going beyond just addressing regulations and increasing access to care. Health plans are part of the communities in which they serve, and many have stepped up to give back.

Colorado-based Friday Health Plans supports local businesses impacted by COVID-19 by placing daily takeout orders from local restaurants to provide meals for their employees. They also partnered with local Blessed Brews Coffee Shop to provide free coffee to essential community workers, including teachers from the Alamosa School District and the Alamosa Police Department.

Health Partners Plans donated thousands of free books that parents of Philadelphia-area children can pick up when they visit local hunger relief nonprofit Bebashi’s food pantry.

Blue Cross Blue Shield of Arizona and Phoenix Suns Charities donated $80,000 for 5,000 COVID-19 antibody test kits for first responders. And more than 20 of the health plan’s medically qualified employees volunteered to work in local healthcare facilities and help provide care to COVID-19 patients.

In Minnesota, Medica donated $1 Million to 18 local nonprofits to meet emergency needs during the pandemic; support will go to children and families, shelters, health clinics, food pantries, mental health/telehealth services, and more. And through its foundation, UCare provided $500,000 to support Minnesotans impacted by COVID-19. They also distributed more than 11,000 individual hand sanitizers across the state and donated bags for packing food to local food banks.

At HealthEdge, we also have looked for ways to give back to our local community. Throughout this crisis, we have donated weekly meals to the staff working tirelessly at the Lahey Hospital Emergency Room to keep our neighbors and community safe.

By helping each other, we will get through this. HealthEdge remains committed to our customers and is working to help them navigate these concerns, and we will be there to help overcome challenges in the future.

Interested in learning more about HealthEdge, our products and services, or want to schedule a 15-minute introductory call to discuss your business opportunities and challenges, contact Janet Barros.