Healthcare Payor Insights for a Changing Industry
In this article
The healthcare industry has witnessed so much digital evolution over the last few years; you might call it a revolution.
The pandemic has rewarded "outside the box" thinking, leading to innovations with technologies that have been available for some time. In addition, new perspectives have spurred novel approaches to rescripting care delivery models, vaccination development, acute care operations, clinical treatments, clinical trials, and unlocked many more healthcare and life science pathways.
Technology was not the only means of this transformation. We also witnessed evolutions in how people work and think about care. For example, we've seen an increased focus on data maturity and robotic process automation practices promoting key clinical and administrative insights. Targeted solutions that help staff work at the height of their scope of practice. Plus, innovative policies and processes (e.g., the public health emergency declaration) that have played a critical role in the modern care revolution.
This article explores three insights our Healthcare and Life Sciences practices have gleaned from our recent work with payors and insurers.
Change is afoot in the payor space
The payor or insurer space represents a significant sector of the healthcare ecosystem.
As it undergoes digital transformation along with the greater industry, we're progressively seeing people want to engage in their care experience. They expect their care journeys to resemble the seamless experiences offered by retail, service, and hospitality industries. As a result, they are actively seeking out more frictionless, affordable, accessible, and comprehensible experiences when they need care.
This shift has been partly driven by non-traditional players like big tech, big box retail, and start-ups. Another influencing factor has been a focus on lifestyle changes and proactive prevention as opposed to episodic transactional sick care, as evidenced by shifting reimbursement models.
In response, we see payors at the forefront taking stock and making strategic investments to ensure they are in position to provide the types of experiences members are expecting.
Below, I outline three areas where payors are progressing in this endeavor.
Payor insight #1: Virtual care
In the context of providing virtual care, providing a seamless platform is top of mind for many payors. A platform where IoT and wearable devices are utilized by members who may need chronic care management or other hospital-at-home needs.
In our practice, we see more and more payors implementing technology, data, people, and process initiatives to monitor vulnerable at-risk populations. For example, some large payors now use remote patient monitoring (RPM) for expecting mothers with high-risk pregnancies to proactively tell if the mom or baby needs intervention.
Additionally, we're seeing payors partner with digital health companies to monitor diabetic patients' physiological data, medication compliance, diet, and exercise while providing clinical guidance to stay within their ideal thresholds – chronic care management. There are many clinical use cases where nascent digital health technology companies offer clear value to traditional payors' members.
As a payor, if you're not exploring the frontiers of virtual care, there's no better time to start than now.
Payor insight #2: Digital-first insurance
The U.S. spends a great deal on healthcare, approximately $3.6T. However, the amount spent doesn't always equate to better outcomes. And it turns out this total amount includes a great deal of waste — about 25 percent ($760B to $935B).
There are many reasons for this waste, including:
- Failure of care delivery ($102B – $166B)
- Failure of care coordination ($27B – $78B)
- Overtreatment or low-value care ($76B – $101B)
- Pricing failures ($231B – $241B)
- Fraud and abuse ($59B – $84B)
- Administrative costs ($266B)
Payors that invest in digital tools focused on reducing waste in these areas will be able to eliminate some of the friction from their members' experience while saving on administrative costs in the process.
Another area of low-hanging fruit involves implementing human-centered digital touch points. These touchpoints, backed by advanced analytics, offer proactive clinical and administrative prompting at the meeting point of your staff's skills and capabilities. Payors who offer these digital tools in support of their services can increase the value for members through a more personalized, unique, painless, and proficient care experience.
WWT is seeing several incumbent payors moving in this direction. However, non-traditional digital health start-ups are still leading the digital-first insurance race, thanks partly to the advantage of controlling their tech stack from beginning to end.
There is still plenty of opportunities for traditional payors to catch up, though!
Payor insight #3: Healthcare wayfinding
Payors know members yearn for a smooth, uncomplicated journey as they travel down the proverbial healthcare highway. This trip should be automated, guiding members from one seamless experience to the next.
This is the vision of next-generation wayfinding based on a digital healthcare roadmap.
Imagine a healthcare journey as seamless as using Waze. You indicate where you want to go and when you want to get there. The technology uses data and advanced analytics to avoid traffic, construction and accidents, and even warns you of speed traps and stoplight cameras. You know your speed, the posted speed limit, and estimated arrival time. In a nutshell, such Waze-like wayfinding helps you anticipate and avoid the unknowns.
Unfortunately, navigating the twisty, potholed roads of healthcare is a frustrating experience for 90 percent of our population.
Yet we're seeing that payors who adopt a digital healthcare marketplace approach, easily understood and used by members, are making headway at streamlining the healthcare journey in some exciting ways, such as:
- Performing digital triage.
- Automatically connecting members to the right level of care in their network
- Communicating the estimated costs of an encounter prior to the visit
- Offering virtual or in-person appointments options based on the reason for their visit
- Allowing members to choose convenient appointment dates and times
- Wayfinding members to the place of care if they're seeing a clinician in person
- Providing easy-to-understand education and supporting personalized care
- Consolidating billing into one simple paymentConsolidating billing into one simple payment
The critical role of IT modernization
As payors begin strategically planning and executing on these critical care-abouts, they'll soon realize that IT environments must be sufficiently modernized to support these types of authentic member experiences. That means taking stock of current IT infrastructure; migrating data silos to an appropriate setting; exploring cloud strategies and operating models; ensuring a strong cybersecurity posture that incorporates automation and orchestration; and investing in other IT foundations that may be required to support their vision of digital transformation.
Newer digital health companies have built their business models around their technology stacks, making it easier to pivot and meet shifting member expectations. This adds competition to the equation for incumbent payors.
With all baby boomers destined to join the 65 or over club in eight years, representing 21 percent of the U.S. population (71M people), the payor industry will only see more Medicare and Medicare Advantage members. What's to stop employers and CMS from contracting directly with these digital health players? Nothing! In fact, during this last enrollment period, we already witnessed how digital-first start-up payors are encroaching on traditional payor's Medicare Advantage market share.
The signs are unmistakable. The time for healthcare payors to join the digital revolution sweeping the industry is at hand.