As the COVID-19 virus continues to riptide throughout the healthcare system, health plans have a pressing need to look beyond the immediate crisis and implement strategies that drive efficiencies across medical management operations to successfully manage the sudden upward and downward shifts in medical costs and utilization.

Nationwide, health plans are frantically working to revise their current business plans to effectively manage the impacts COVID-19 has had and will have on medical costs, utilization and member health statuses. Today, the healthcare system is largely flooded with costs tied to COVID-19 treatment and testing and much of these costs will be absorbed by health plans. A recent study published by America’s Health Insurance Plans (AHIP) and conducted by Wakely1, estimate the average total COVID-associated treatment and testing allowed costs to be between $34 and nearly $140 billion dollars across 2020. In the same study, the enrollee cost sharing portion was estimated to be 14-18% of annual allowed costs, representing a range of $10 to $78 billion in potential enrollee cost sharing.

The surge in COVID-related costs and utilization comes with a plummet in non-essential healthcare service delivery. This scenario exacerbates matters as a large percentage of procedures unrelated to COVID have been cancelled or postponed, and will likely create a swell in utilization once restrictions around non-essential procedures are lifted. Many believe this delay will help offset costs for health plans, however, as planned utilization returns to the healthcare system a spike in healthcare costs will likely be seen.

So, what does this all mean for healthcare payers?

With much uncertainty ahead of us, one thing is crystal clear: health plans are going to see volatility across utilization and costs for some time.

As costs rise and utilization trails right behind, it will be imperative for health plans to find ways to create efficiencies across medical management operations to contain costs and offset fluctuations and surges in utilization. Efficiencies can be the difference between successfully operating during these times of planned and unplanned surges in costs and utilization, and falling short when volumes climb.

Now is the time to make change happen. Below are a number of practical efficiency strategies health plans can implement today to help keep control over medical costs.

Leverage Data & Analytics to Drive More Intelligent Programs

As health plans looks to move faster with fewer people, all while delivering greater outcomes, they have a real opportunity to make better use of data and analytics to gain insights that impact performance. These insights provide visibility into where the most strategic opportunities exist for change. Change across a variety of core areas impacting medical spend include member health outcomes, resource allocation and overall program design and performance.

Below are a number of ways in which data, analytics and insights can be used to create efficiencies and drive improved medical cost outcomes.

Analytics to Create Highly Prioritized Member Outreach & Engagement Plans

Today, the impact on short- and long-term population risk is still highly unknown. What is known, however, is providing care to the highest risk and most vulnerable populations is critical to keeping costs down and quality outcomes up

With the right data and analytics, heath plans can prioritize resources and drive action plans to outreach to the members most in need of care. Some members may be avoiding the healthcare system due to the risk of contracting COVID, yet their underlying health condition(s) is going unmanaged. While COVID risks are still high, health plans can work with providers to identify these vulnerable members and prioritize outreach priorities via telehealth. Other populations may have contracted COVID-19 and are now managing new health risks. Some members may have postponed scheduled procedures and their conditions either worsened or became compounded.

In any case, serving the members most in need of care is instrumental to containing healthcare costs. To focus resources in the most efficient and effective ways, predictive and prescriptive analytics can help prioritize engagement and outreach. Matters today call for health plans to go beyond traditional risk stratification by further prioritizing clinical resources based on the most Impactable and Intervenable members. These members will not only deliver the greatest clinical and financial return if health improvements are made, but are likely to be the most willing and able to engage and improve health outcomes. Based on known clinical history, social determinants of health, behaviors and more, they are most likely to comply with given treatment plans and take necessary steps to manage their health.

Instituting More Intelligent Program Design & Processes

Data and analytics can be used to look across current programs to find areas where efficiency opportunities exist and a return on investment will be seen. One area for analysis may be Utilization Management operations. Analytics can inform whether programs are focused on the right pre-authorizations or, whether some providers qualify for gold card status. Streamlining authorization lists and ensuring resources are focused on reviewing high-value services or those services most costly to the organization can create significant shifts in productivity and medical cost impacts. When health plans search for ways to manage more with less, analytics can be an enabler to tightening program design, performance and outcomes.

Technology to Create Faster, More Efficient Workflows

One of the most effective ways to create efficiency within operations is through the use of the right technology. As mentioned previously, the general population today is avoiding using clinics and hospitals as much as they can, by postponing routine visits, procedures, and/or electives. Eventually, this pent up volume will likely come back into the system at a more concentrated rate, especially if concerns increase about a potential return of the virus in the fall.

To handle the predicted volume while operating at a faster speed and with fewer people, there are technologies that will enable health plans to better manage volumes in utilization by automating and streamlining workflows.

A medical management system embedded with the right analytics is critical to efficiently keep pace with surges in utilization. By automating and streamlining workflows, health plans can move faster with fewer people, and handle greater volumes.

When evaluating current platform capabilities, one should look for the following key enablers of efficiency:

  • Analytics and digitally enabled workflows that automate manual processes and create more intelligent operations
  • Flexibility and compliance to meet unique organization needs
  • Transparency and collaboration across key stakeholders and care management programs
  • Smarter methods for member and provider engagement and outreach

Other value can be seen by implementing a safe, user-friendly provider portal. Integration between provider portals and a health plan’s care management platform can drive significant efficiencies across workflows as well as support provider satisfaction.

Automation to Speed & Eliminate Labor Intensive Operations

In today’s environment, there is a number of ways in which health plans can infuse UM operations with digital technologies to eliminate manual, labor intensive workflows.

By evaluating current UM operations and identifying opportunities to apply digital technologies, health plans can position themselves to take on far greater volumes than ever before. Such technologies as Natural Language Processing (NLP), Artificial Intelligence (AI), Machine Learning (ML), Robotic Process Automation (RPA), and much more, eliminate the need for manual interventions across UM functions such as Intake and Clinical Review. One simple example is applying automation to clinical intake. Instead of a live intake agent manually processing a fax request, automation can be applied to fetch required information needed to create a new request and assign to a clinical reviewer. Another example uses an automation solution comprised of NLP, ML and RPA to pull data from multiple systems and serve the required data to a clinical reviewer in order for a determination to be quickly made.

Chatbots, Conversational Interactive Voice Response, and other digital virtual assistant solutions are highly effective within call centers. These technologies serve to speed time to resolution across member and provider call inquiries.

These examples demonstrate the power digital technologies can have on freeing resources and the ability to manage greater volumes of utilization in a far more efficient manner.

Today, all players across the healthcare system are striving to keep pace with current and evolving needs stemming from COVID-19. These same players should be evaluating and quickly implementing new strategies to prepare themselves for the widespread impacts on our healthcare system’s cost, quality and utilization. Time is of the essence, and healthcare payers should act quickly.

America's Health Insurance Plans [AHIP], 2020. 556-billion-over-two-years/.

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