 Emily Graham

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Value-based care has gained significant traction in the U.S. over the past few years, and for good reason. With healthcare costs outpacing income growth and health insurance deductibles increasing by 212% over the past decade, many patients are left feeling that their health insurance doesn’t provide as much value as it did 10 years ago

Meanwhile, recent price transparency data has revealed that, on average, hospitals charge private payers more than twice the amount they charge Medicare and Medicaid. As a result, employers who offer employer-sponsored health insurance are increasingly demanding that payers take a more active role in reducing the cost of care. Developments like the Anthem-Parkview contract negotiations have sent a strong message to payers—look for ways to lower costs or lose your most profitable line of business.

Many payers are taking this message seriously and working with providers to implement risk sharing arrangements and value-based care models. Although these models can help cut costs and improve health outcomes, they also face a variety of challenges: “value-based care” measures (such as admission and readmission rates) that are not tied to health outcomes

), and payers placing the responsibility of controlling costs onto providers. Providers are hesitant to enter such arrangements due to the higher financial risk, operationalization barriers, and additional cognitive strain associated with these arrangements (

These challenges raise an important question: how can payers reduce the cost of care and improve health outcomes for their members? Ultimately, payers will have to take a more active approach to value-based care by leveraging data to find targeted opportunities, collaborating with providers, and supporting investment in medical technology.

Although most payers collect vast amounts of data about their members, few of them have unlocked the full potential of this data. Payers—especially those involved in integrated delivery networks (IDNs)—need to use this data to extract insights about their members, communicate these insights across functions, and identify opportunities to create meaningful interventions.

Many payers recognize the importance of data-driven insights and are already taking steps to improve their data analytics capabilities. In fact, a recent report found that 74% of health executives were planning to invest in predictive modeling this year

But data analytics alone won’t lower healthcare costs and improve outcomes—especially when organizations keep their data siloed, don’t communicate their data well, or lack holistic data that includes social determinants of health and community factors

. Payers must use their wealth of data (which, for IDNs, includes both claims and EHR) to find targeted opportunities and create population health initiatives. These initiatives should aim to stratify risk and target specific populations with actionable opportunities that reduce time to value.

We are frequently asked to help healthcare companies leverage their data to create predictive models and identify areas of opportunity. Over the course of nine weeks, we helped a large population health client develop a predictive model to identify members at high risk of falls. The client used our model to design population health interventions, preventing an estimated 75-100 falls per year and providing cost savings of $30M per year.

2. Collaborate and Build Trust with Providers 

Payers also need to collaborate with providers to improve care quality and build trust. Currently, payers—especially those involved in risk-sharing arrangements—are exerting downward pressure on providers’ margins and providing little support for reducing the total cost of care. Between this lack of risk-sharing and the administrative burdens that insurance adds to provider workloads, providers may view payers as inhibiting their ability to provide high-quality care. Going forward, payers need to introduce more upside risk and provide incentives that align with provider goals.

Care pathways would particularly benefit from payer-physician collaboration. Payers could work alongside providers to identify at-risk populations and support referrals to participating providers. Specifically, payers could involve providers in identifying risk factors that might good indicators for predictive modeling. They could also co-create care pathways and reduce providers’ administrative burdens (e.g., prior authorization). These initiatives could help providers meet their targets, improve care quality for patients, and build trust between providers and payers.

Finally, payers should consider investing in medical technologies that can lower long-term costs and improve health outcomes outside of the existing claims and reimbursement structures. Many payers are already working alongside providers to implement advanced tools and technologies for large, high-cost member populations. For example, Cigna is working with Cricket Health

, a comprehensive kidney care provider, to support chronic kidney disease (CKD) patients. Cricket Health uses a machine learning algorithm to identify members at high risk for CKD, then deploys care management solutions to reduce hospital admissions and disease progression rates. While these investments can improve care for large member populations, payers should also look to adopt tools that can improve care for smaller member segments with conditions that incur high medical costs for businesses—for example, neurological conditions.

Neurological conditions represent large areas of opportunity for payers. The single most common neurodegenerative condition is Alzheimer’s disease, which impacts 6 million patients across the U.S.—but over 50% of Alzheimer’s patients are either undiagnosed or unaware of their diagnosis

. Implementing AI-enabled imaging technology at the beginning of the care pathway could help these patients get diagnosed and treated earlier, ultimately improving quality of life and slowing disease progression.

In other areas, AI-enabled imaging technology can improve providers’ workforce efficiency and imaging quality, thereby increasing healthcare utilization and value. Another high potential MedTech area is patient monitoring solutions, which can improve the patient experience by facilitating patient-provider connections. These solutions can also help drive member steerage. Finally, remote symptom management solutions allow for more touchpoints between patients and providers, improving provider visibility into their patients’ post-treatment profiles. The improved visibility can help slow disease progression and mitigate risks, such as unnecessary hospitalization or medication non-adherence.

Over the past decade, value-based care has become a popular buzzword among stakeholders across the healthcare system, but its benefits have yet to be realized. Fortunately, payers have several opportunities to help accelerate the transition to value-based care. These opportunities include using data to design targeted health initiatives, collaborating with providers, and supporting investment in medical technology. Ultimately, these interventions can help protect payer profit margins and streamline provider workloads while reducing costs of care and improving health outcomes for patients.

Emily Graham is a healthcare expert at PA Consulting. She is focused on helping health payers transform their operations to meet the demands of a rapidly changing industry.

 is a healthcare and life sciences innovation expert. He leverages his background in health policy and understanding of healthcare dynamics to bring innovative medicines and health solutions to market globally.

 is a healthcare and life science expert at PA Consulting. She is focused on improving communication within healthcare systems and life science organizations to help business functions translate data into action.

Articles

With healthcare costs outpacing income growth and health insurance deductibles increasing by 212% over the past decade, many patients are left feeling that their health insurance doesn’t provide as much value as it did 10 years ago.

Paying it Forward: How Payers Can Accelerate the Transition to Value-based Care

The emerging challenge of healthcare in a world full of social distancing and quarantine has created a secondary challenge for the U.S. health system. Critically, healthcare providers have dedicated the majority of their resources to dealing with the front line of the coronavirus. This has left a gap in everything from non-emergent care to understanding future healthcare options and coverage for individuals in uncertain times.

A massive number of Americans are under shelter in place orders. Leaving only digital and virtual channels available for people to engage with the healthcare system and to seek answers to their healthcare questions. Due to the resource constraint that providers are currently under, people are turning to and will need to turn to healthcare insurance plans for answers, and in some cases to assist with longer term care needs.

However, digital engagement has not traditionally been a strength of health plans, or the U.S. healthcare system in general. Most plans have websites, apps, social media presence, and telehealth channels available, but operationally, they are unprepared to adapt to ever-changing questions and needs of their members. A prime example is the unprecedented growth in demand for telehealth services, with one service provider reporting demand increasing 300% nationwide. Data on wait times is sparse, but anecdotal information and news stories are reporting people holding at times for many hours. 

In addition to the increased demand, there have already been significant changes made to regulation to help ease the crisis. Health plans need to be able to help members, prospects, and the general public understand what these changes mean for them. 

Six Telemedicine Concerns Plaguing Health Industry

This is clearly an intensely unsettling and disruptive event for individuals and the industry. How can health plans best meet the needs of this new and captive audience digitally, today, so they can build trust and capabilities for the future? Now is the time to establish strong digital capabilities. To be successful, health plans must continually use the data and information that is available through digital channels to listen to and learn from members, then adjust content to answer their questions. Rapidly assessing and responding to their needs today will build both a lasting member relationship and enhance future digital capabilities. 

members and prospective members are asking 

Over the past few weeks, the information members are seeking from health plans has changed significantly. Searches are up for finding in-network providers and viewing claim statuses to understand specific coronavirus coverage care and how to access telehealth professionals. The reason these interactions and information members are seeking services will continue to evolve quickly and it is imperative that healthcare payers look for those changes and adapt content accordingly. This is a critical first step toward becoming the trusted source for reliable health information and care.  

Health plans have tools and data to accommodate these requests and searches. There is no need to invest in new technologies. Most companies collect analytics from their websites, social channels, apps, and contact centers. It's important to focus on the insights that can come from or be inferred from available data now, not the data to be collected next year.  

Basic information on what members are reading, searching for, trying to access, and calling about will provide the core of this insight. The ancillary information about how long and how frequently members engage with health plans will show successes in delivering the tools, information, and experience needed. The most effective health plans will go beyond creating dashboards and metrics and instead focus on highlighting actions to respond to the changing needs of their members.  

Dynamically tailor content to answer those questions 

Once the insights have been gleaned, health plans should coordinate amongst the digital, marketing, and IT teams to understand what changes can be made to address the needs and collaborate with other subject matter experts as needed. For example: 

Are members increasingly looking for information that is available but perhaps a few clicks buried on the website?

 Consider bringing a link to that information to the top of the landing page. 

Is your landing page filled with rich content that members seem to be getting lost in?

 Look for opportunities to simplify messaging, rearrange content, or declutter information that is displayed. 

Is the answer to the question not available through digital channels?

 Pull in multidisciplinary teams to answer the question accurately and effectively, nail down the messaging, and get it posted. 

Are there common questions about plans that the call center continues to field?

 Build out self-help options, point users to other digital channels, and ensure the information you're pointing them to is clear and concise.  â¯ 

Health plans should be using all digital channels to signal to users that they are being heard. Create social media posts to drive traffic toward timely topics through the best available digital channels. This information is top of mind for the general public, members, and prospective members, and is helpful and valuable to share now.

Don't stop listening, learning, and responding

Health plans can monitor interactions by adding new tracking tags to digital channels to understand if the changes that were made are answering member’s questions and identifying additional changes that could be made to further meet member’s needs. The trust built with members will continue to grow as they feel they are heard and responded to. Similarly, health plans can create an empowered, insight-oriented, digitally savvy culture that can spot patterns quickly, find a solution, and implement the change in a fraction of the time it takes today.  

This change is not just needed to respond to the coronavirus, it is key to the survival of health plans in an increasingly digital world. It is possible that current events will end up kick-starting a new wave of digital health engagement. If that is the case, those who are able to quickly listen, learn, and respond to their customers' needs will benefit from a deeper level of member trust, engagement, and enhanced digital engagement capabilities built and tested out of necessity. 

Emily Graham is a healthcare expert at PA Consulting. Graham is focused on helping health payers transform their operations to meet the demands of a rapidly changing industry. 

With the use of virtual and telemedmedicine services increasing, health plans must continually use the data available through digital channels to listen to and learn from members, adjust content to answer their questions, and respond to their needs, to build both a lasting member relationship and enhance future digital capabilities.

Emily Graham

Articles

Paying it Forward: How Payers Can Accelerate the Transition to Value-based Care

Steps Payers Can Take to Meet Changing Digital Needs of Members