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Health plans that implemented a core administration system twenty years ago and have only taken technical upgrades for two decades struggle to efficiently operate in today’s market. The failure to design their processes around flexibility to adopt the enhancements delivered to them over the years puts health plans at a competitive disadvantage.

And while the system may look better today, it’s not performing any differently than it did in the ’90s. Furthermore, the health plan is not getting any value from the additional code they are paying for in their maintenance and licensing agreements.

CTOs and CIOs in this situation must ask themselves:

–         Why is your organization operating the same way as you did 20 years ago?

–         Why aren’t you taking advantage of any new enhancements?

The typical answer is that the time and cost associated with implementing the enhancement and learning how to use the new solution are too high.  Change is expensive unless we build a culture of continual optimization.

At some point, if payers simply let business users run the core administration system without focusing on the outcome of why they execute a certain process, it will result in “paving the cow path” and they ultimately just achieve inefficiency faster in a better-looking system.

Enhancements and upgrades add value, give health plans a competitive advantage, and allow organizations to operate more cost-effectively. Health plans must have the ability to adopt enhancements, have confidence they will work, and the flexibility to build on those functions and align their strategy to the Product Roadmap.

It comes down to whether a health plan has the culture that will continually take enhancements and not find themselves painted into that box twenty years later, wondering how they let so much time slip by.

I’ve seen this happen to numerous organizations, and I wonder what led them down this road? A health plan can look at a timeline of all the different versions of enhancements and upgrades that they ignored and correlate these milestones with potential opportunities they missed that could have advanced their business. Even though they had all the tools, answers, training, and resources at their fingertips, they just were not open to changing what they already knew and updating the way they operate.

For health plans that fear change, my advice is to embrace the upgrades that feed into continual optimization processes and allow your organization to make progress in the future.

For health plans, operational efficiency could be the first step in their approach to innovation. While it may not be the most exciting aspect of the business, achieving operational efficiency will enable them to remain competitive in the long-term.

A health plan can have the most innovative ideas in the world, but without the resources to back it up, they most likely will not get very far. Operational efficiency, automation, and accuracy free an organization to focus on innovation. By prioritizing operational efficiency, organizations can redeploy the time and resources typically spent on routine  administrative tasks, and shift to transformative projects.

Flexibility and agility are also incredibly important. A health plan with great ideas for new market-competitive products that advance the organization’s innovation goals requires the technology flexibility to configure and automate them, along with the ability to make changes quickly. Otherwise, they will end up losing momentum and missing out on crucial business opportunities.

Health plan innovation touches many aspects of the organization, including member engagement, payer-provider collaboration, and business processes, and in many cases, impacts benefit designs, provider contract designs, and other aspects that help drive behavior. To remain competitive, health plans must have the freedom to test new ideas, try modeling, make mistakes, and access their data in real-time to see what works and continue improving.

When it comes to implementing innovative ideas, a core administration system that breaks down product design barriers, increases efficiency, and delivers real-time transparency is a necessity. If the majority of an organization’s ecosystem is cutting-edge, but the core administration platform is outdated, everything else will fall behind. Healthcare moves fast, and health plans need the ability to be forward-thinking.

All of the health plans I talk to have incredibly innovative ideas. They want to invest in a meaningful member experience, they want to enhance payer-provider collaboration, and they want to transform their organizations. To achieve these goals, they need a system that empowers them to focus their skills, experience, and capabilities on actively impacting the true health of their individual members and the U.S. healthcare system as a whole.

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.