Top 5 Challenges Facing Health Plan Leaders in 2024

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 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.