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The seminal moment COVID-19 provided our industry over the last couple of years has refocused the spotlight on two critical topics: health equity and value. The health equity crisis, although known for a while, took on new meaning as furloughs and other economic mitigation strategies estranged more people from their benefits, making equality in access a hymn sung by a much louder choir. Again, an intuitive truth all along, the simple concept of demanding value for every dollar spent returned to vogue as CMS renewed its commitment to value-based payment models and their simplification, applying the learnings of the initial ACO era. 2022 will not be about tackling these two threads head on, but rather, industry leaders realizing they fit together hand-in-glove and that in their intersection lies the power to advance both. 

We will see acceleration in a morphing definition of high-performing networks to include the orchestration of medical and non-medical resources. Those organizations that shift their technology investment toward building core competencies around information capture, information digitization and sharing, automated contract management and payment facilitation that span all network partners--medical and non-medical, upstream and downstream, regardless of site of care--emerge from 2022 with competitive advantage.

Calum Yacoubian, M.D., associate director of healthcare strategy,

With CMS’ approval and enforcement of the Interoperability and Patient Access final rule, payers will need to expand their ability to provide patients access to their own health data. including unstructured data that is generally difficult to surface. Payers also need access to accurate, holistic member data to properly assess patients’ health status, rigorously assign risk adjustment and proactively identify gaps in care. Unfortunately, as much as 80% of all patient data is unstructured: it is trapped in the notes sections of EHRs and not readily available for analysis. This unstructured data typically contains critical details about patients’ symptoms, disease progression, lifestyle factors and lab tests, for example. To minimize the need for time-consuming and inefficient manual searches of patient charts, payers will increasingly turn to artificial intelligence-powered tools such as natural language processing that will support the management of mountains of data at scale.

Look for contract-based analysis to be used by Medicaid managed care organizations (MCOs)  in 2022 to optimize profitability in downside risk arrangements. Analytics will identify which members represent significant avoidable utilization and segment them, 

 predictive analytics, by the probability of developing chronic conditions. These insights will catalyze efforts by MCOs and aligned resources to engage members with early intervention and preventive care. 

However, it’s difficult for payers and providers to grow analytics models ‘at home’ now due to the necessity of additional data for downside and shared-risk models, as well as the requirements around process and outcome tracking and proving compliance with payment model stipulations. Thus, we can expect to see alliances with analytics providers or competitive hiring of data scientists next year in anticipation of future demands.


As interoperability ramps up and payers become more accustomed to the secure exchange of healthcare data via application programming interfaces (APIs) and other means, the industry will more fully embrace digital technologies to reduce the burden of various administrative processes, including prior authorization. The continued push for consumer-centric healthcare is driving renewed interest in stronger collaborations with providers to proactively manage patient care. Instead of viewing member health from a population health and strictly utilization management perspective, payers will use digital platforms to partner with providers in the creation, approval, and execution of evidence-based care plans designed to improve outcomes; reduce readmissions, complications, and length of stay; and contain costs.

Brian Russell, director of integration services at 

Important progress has been made this past year since the passage of the Office of the National Coordinator for Health IT’s (ONC's) 21st Century Cures Act and other legislation. In 2022, I expect the mandates of FHIR resource integration and APIs to be in full focus, as well as the conversation on a data-first approach to care and interoperability as it is key in driving better patient outcomes and care to be at the forefront. Interoperability is a starting point in the journey with healthcare data, which is growing exponentially and becoming more abundant as it is generated from consumer-driven technologies and sources. It is more important than ever to arm the healthcare ecosystem with technologies to ingest, enrich and derive meaningful insights from big data to facilitate a proactive approach to care.

Nicholas Loftin, director of Virtual Care at 

Although remote patient monitoring (RPM) has been around for a long time, it is poised to grow in use both with overall utilization as well as across a greater number of use cases. Typically, RPM has been utilized to primarily support chronic disease management. We are now seeing more patient and health centers leverage it in varying uses, such as general health monitoring and to facilitate hospital at home programs. 

Because COVID-19  increased the need for virtual visits, we saw a marked increase in patient utilization and adoption. From this, we are seeing many new entrants to the market that solely offer services through a virtual platform. In order to provide these services, their providers have been cross-licensed in various states, and thus can provide services to any individual, no matter their geographic location. Due to the challenging nature of payer contracting when providing services to such a large geographic area, these organizations are pushing for self-pay instead of going through a patient’s insurance.

Danielle Grasso, senior product manager at 

The shift to consumerism is an ongoing trend in the industry. As healthcare is digitalized, patients have increasing access to endless amounts of comparative data and quality information that they can use to choose their provider and hospital. In 2022, providers and health systems will need to increase their focus on the patient experience in order to gain and maintain a good reputation in the market.

Richard Brooks, president, healthcare, at 

During the pandemic, seniors and vulnerable populations became more dependent than ever on their care circles, including everyone from children and grandchildren to neighbors, professional helpers and healthcare providers. We will see mobile apps that bring together these care circles to reduce social isolation, deliver access to tools that address social determinants of health (SDOH), and provide a unique view into the member’s home, well-being, and activities. This next wave of digital health innovation will facilitate gracefully aging in place while being able to predict and trigger earlier interventions when the need arises.

Neeraj K. Sharma, chief operating officer and co-founder of 

Heading into 2022, we believe that there is room for improvement in payer-provider relationships, which can be rectified by agile provider onboarding. Payers should embrace the option to pursue enterprise-wide provider network management solutions that reduce unnecessary costs and inefficiencies while improving provider and member satisfaction. This will go a long way towards the industry's broader goals of value-based care and services based on quality rather than quantity.

Covid-19 highlighted the unfortunate realities of vaccine, transportation and food deserts that make healthcare access so difficult for vulnerable populations. In 2022, the healthcare ecosystem must realize and acknowledge the need for a fully integrated digital health model and scaled solutions that address the social determinants of health. Digital tools such as remote patient monitoring and health apps that broaden access and reduce complexity can enable underserved populations to begin to close health equity gaps that have arisen because of these social determinants.

Rob Cohen, president and general manager of 

We have significant problems facing us in healthcare: the COVID-19 pandemic, the opioid epidemic, a mental health crisis, and the staggering impact of chronic conditions. We have to leverage every tool in our toolbox, including technology, to overcome our obstacles. Care coordination requires interoperability between the electronic health records of primary care practices, specialists, hospitals, labs and payers. Quality healthcare relies on the ability of providers to share patient data and coordinate care. As we continue moving toward value-based care, technology serves as a connector, breaking down silos to improve care coordination and positively impact outcomes across patients' physical and behavioral needs.

Colin Banas, M.D., M.H.A., chief medical officer, 

The drive toward consumerism will continue to gain momentum as patients have had a taste of virtual care. Up until now, telehealth experiences essentially have been a one-to- one replacement for an in-person visit. But we’ve only just scratched the surface of what true remote healthcare can be. 

Advanced analytics for remote patient monitoring could help clinical teams see past the noise of data to spot critical trends to trigger interventions for better patient outcomes. Mobile medical units could come to patients’ homes for services previously only available in healthcare facilities, such as blood tests, intravenous fluids and antibiotics, and even x-rays and ultrasounds. Consumerism also means that patients will have easier access to their health data with the 21st Century Cures Act and new mobile apps that help people keep track of their records.

Leading health plans will continue to lean further in on providing supportive technology resources for their provider networks, especially technology that relieves administrative burden and supports value-based care. This will be the next generation of reducing provider abrasion and enabling payer-provider collaboration, which is what’s needed to move our health system forward. Interoperability, integration, and data-sharing will come together in new and meaningful ways to close gaps, improve care, and enable the partnerships needed for transformation.

The pandemic has underscored the need for health plans to become more proactively member-focused. 2022 will continue the trend of centering the member experience. Payers will adopt more member engagement platforms to influence behavioral change, facilitate access to virtual care, and connect vulnerable patients to providers. Expect payers to rely more on data analytics and data as a service (DaaS) technologies to create new population insights that will fuel the slow progression of value-based care collaborations with providers. Organizations will need to improve their management of interfacility patient transfers by accounting for factors such as patient acuity, distance, available transport resources, and the capabilities of receiving facilities. This will lead to an increased use of patient movement platforms to assess patient needs, locate appropriate receiving hospitals, and navigate the logistics of interfacility transfers more efficiently.

Health data quality will become an increasingly important priority for payers in 2022. Health plans and ACOs will strive to improve digital data quality by eliminating patient data record duplications, which lead to denied claims, billing errors and delays in prior-authorizations and final reimbursement. This will require an investment in health data management systems that are intelligent and automated, and that enhance data exchange with provider organizations. Payers also will be more reliant on data analytics and how they can be applied to SDOHdata to reduce healthcare costs and improve patient outcomes.

Damon Auer, chief executive & general manager of North America, 

Price transparency regulations from CMS should not be viewed as just another compliance check-box requirement, but an unprecedented opportunity to help members better understand care options and costs in a personalized way. Payers that chose to lead and innovate when it comes to member experience—including price transparency—will be ahead of the curve in the coming year. Additionally, it will be important for payers to get creative and adopt a consumer-first mindset about how to curate, shape and best utilize transparency data. The phrase 'interoperability with a purpose' means not just giving access to data to members for data’s sake. It means doing the extra work to turn that new pile of data into personalized, actionable, valuable information for each member.

Health plans will start to think of data as assets that can drive value exponentially throughout their organization. They will ingest clinical documents at an enterprise level and use innovative technologies to normalize and organize content. Documents will be processed once and data made accessible across different departments, from payment integrity to risk adjustment. Workflows involving humans reading medical records will be heavily automated and a fluid data strategy will prepare health plans for future reporting needs.

Articles

Healthcare executives look ahead to 2022 and the forces and events that will shape the American healthcare landscape.Amendola Communications compiled these comments from a variety of healthcare executives.

Amendola Communications

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Predictions for 2022 from Healthcare Executives