The following is a guest article by Mike Pattwell, Principal Business Advisor, Value Based Care at Edifecs
Consumers are at the heart of healthcare — their fears are forcing healthcare innovators to shift priorities to deliver consumer-centric digital health offerings. This is true today, tomorrow, and far into the future.
With inflation brings financial concerns that lead to cost-cutting efforts often resulting in poorer health outcomes from millions of Americans. Consumers are looking for smarter ways to save on healthcare, forcing insurance providers to make marked changes to the way they conduct outreach and how they interact with their members.
Inflation, the COVID-19 pandemic, and healthcare staffing shortages have reshaped the industry landscape. McKinsey & Company estimates there is a $1 trillion healthcare improvement opportunity available by “redesigning their organizations for speed-accelerating productivity improvements, reshaping their portfolio, innovating new business models to refashion care, and reallocating constrained resources.”
Healthcare consumers’ outlook on the future and the state of the economy is putting pressure on health plans to step up in ways we haven’t seen before. They’re forcing health plans to stretch beyond merely processing claims and easing how consumers find their next provider. We’re watching three trends that, if taken seriously, will surely help health plans capture their share of that $1 trillion healthcare improvement opportunity.
Inflation will push Payers back into the Public Marketplace whether Statewide and Federal Health Exchanges, Medicaid and Medicare
Before the pandemic, many payers left statewide health exchanges as they found more ways to become profitable outside of the public market. Reviewing the national enrollment numbers since the onset of the pandemic we find that the pandemic did not cause an influx in enrollment to state and federal exchange offerings by healthcare consumers. The enrollment numbers stayed consistent from 2017 to 2021 staying between 11.5 to 12.2 million. The past two years have seen the enrollment numbers surge to 14.5 million in 2022 and 16.3 million this year. This increase has brought back the payers that exited the public market. This can only be a result of the mounting inflation concerns and the mixed economy. Many larger national payers have once again put their cost-effective products in the public market knocking out smaller health plans on price. If the economy continues to deteriorate it is estimated that we will continue to see 20% increases in public market enrollment year over year.
In the same time period we have seen a large surge in Medicaid enrollment. This initially was caused by the pandemic and has continued due to the poor economic conditions forcing more families into poverty levels. Pre-pandemic Medicaid numbers stayed steady in the 74 – 76 million beneficiaries’ level between 2017 and 2020. Post pandemic and exacerbated by the inflation that number has ballooned to 93 million this year.
Introduced to Congress on April 3 the “Strengthening Medicare for Patients and Providers Act,” is intended to help Medicare payments keep pace with economic challenges like inflation. Healthcare stakeholders are looking for ways to find support among financial uncertainties. This bill, for example, ties the Medicare physician payment schedule to the Medicare Economic Index, which aims to protect older adult Americans covered by the federal plan and sustain affordable, high-quality care.
Consumers Finally take Advantage of Up-and-Coming Commercial Applications to Store their Data and to Search for the Best Health Plan
In 2020, the industry put healthcare data in consumers’ hands through implementing application programming interfaces (APIs). We’ve seen third-party vendors join forces with larger healthcare entities like Milliman IntelliScript did with OneRecord. Data input means data output. Vendors will finally be able to use this data to suggest health plans for members. By the end of 2024, these applications will be used frequently by healthcare consumers and will render payer portals as a thing of the past.
Thanks to the rapid development and push for digital tools and apps to track vaccination status, reactions to the vaccine and future dose reminders, and COVID-19 test results, health care consumers are growing increasingly aware of what it means to have access to their health information. Consumers are accustomed to sharing personal data, such as an address and birth date, in exchange for instant availability of information, grocery and meal delivery, and even meeting like-minded people or dating. This is forcing traditional industry stakeholders to rethink the future of healthcare data privacy and transparency in data collection and sharing. For example, according to a 2019 study by Accenture, a larger population of Generation Z—those born between 1997 and 2012, is “dissatisfied” or “very dissatisfied” with many traditional aspects of care, including effectiveness of treatment, convenience of location or channel, and price and operations transparency, compared to all generations before them. Given this cohort’s different views on traditional healthcare, a shift towards personalized and data-driven health care is inevitable, and value-based care credentials will be a key factor in how the healthcare industry measures success against these new and greater expectations.
Payers are Under More Pressure to Automate the Prior Authorization and Collaborate with Providers
As states continue to adopt their own prior authorization laws, payers are getting creative with how they comply with individual state guidelines. Prior authorization has become increasingly burdensome for all involved – patients, providers, and health plans. We won’t see substantial improvement unless we address the entire process and workflow between health plans and providers. Most of the technology aimed at automating prior authorization is built for a health plan or a provider, but not both. What is more a business problem rather than only an IT challenge, payer organizations need to address prior authorization collaboration workflows and payment processes, EHR integration, and adopt technologies like artificial intelligence, including machine learning and natural language processing, and FHIR® Standards.
Overall, consumers are charting the way forward in healthcare. Their needs and concerns are forcing access to better, more affordable healthcare; that access must be user friendly, which further drives home the need to innovate processes. Keeping pace with rising costs and making changes to help consumers along in the evolution of healthcare will help unlock access to potential funds in the marketplace.
