ProgenyHealth recently attended a national virtual summit that brought together health plan leaders from across the health insurance industry to discuss ways to help businesses prepare and prosper from the changes that are both advancing and disrupting healthcare.
Here are Five Key Topics participants addressed:
Health Equity, SDoH, and Maternal Health
Maternal Health, Health Equity, and SDoH have emerged as a trifecta driving poor outcomes in our nation. In the United States, people of color face a disproportionate likelihood of adverse health problems – outcomes that are systemic, avoidable, and unjust.
Contrary to common perception, increased income does not protect people of color from poor outcomes. Every county in the US has an infant mortality rate for Black mothers that exceeds the white infant mortality rate. Maternal mortality is three times higher for Black women than for white. And, each year, approximately 150,000 babies are born to moms living in maternity care deserts or communities without a hospital offering obstetric care or obstetric providers. Bottom line: the United States ranks the worst in maternal care and has the highest maternal death rate.
A growing body of research also shows how Social Determinants of Health (SDoH) drive Medicaid costs. SDoH are the conditions where people live, learn, work, play, and worship that affect their health and quality of life. One study showed how a Medicaid-managed care organization could reduce its healthcare costs by 10% by solving SDoH issues. In the study, connecting people to social services delivered $2,443 per person per year in savings.
Out-of-pocket costs are impacting health
Access to health coverage is rightly seen as the solution to a host of health problems while also offering peace of mind. Despite the critical role of employer-sponsored healthcare, many covered workers still cannot afford care.
For a growing number of workers, the shift to high deductible plans has made adequate care stubbornly out of reach. Yet, these high deductible plans are often the only option – a trend that started a decade ago when employers wanted to make sure their workers had “skin in the game.” If health consumers had to open their wallets every time they visited a doctor, the thinking went, they would be more selective and less wasteful when using their medical benefits.
High deductible plans can shift $5,000 to $6,000 to the worker’s responsibility. Not everyone has that kind of money at hand. Even though high deductibles lower the cost of monthly premiums, the risk of crippling medical debt goes up.
Even when costs are stable, out-of-pocket costs can rise. For example, for women with employer-based health insurance, the average amount spent out of pocket for maternity care increased from $3,069 in 2008 to $4,569 in 2015. During this same period, maternity care costs remained stable, which means patients were paying higher deductibles.
Among the statistics cited at the conference:
- 2/3 of adults worry about unexpected bills,
- 1 in 4 consumers can’t pay a medical bill greater than $400,
- Even though fewer Americans used their plans during the pandemic, costs still rose by 4.1%,
- 83% of covered workers now have a deductible, up from 70% a decade ago.
While everyone was sheltering in place during the 2020 pandemic, Americans also avoided doctor’s appointments and postponed elective surgeries. Employers enjoyed a temporary windfall as spending declined, yet hospital providers lost a key revenue stream. Some were forced into dire financial straits even while facing unprecedented hospitalizations from COVID. Some hospitals merged with mega-sized health systems or shuttered altogether.
Providers have struggled in other ways. Through ACO mandates, some health plans have developed value-based contracts with parts of their provider network. Yet most providers have not adopted payment models that carry this downside risk – models where the provider is responsible for some of the loss if spending rises above a benchmark for a medical condition. For this to happen, providers and plans will need to closely collaborate so that both parties have the information they need to perform better. Realistically, such collaboration is a long-term process.
Today, with the increased availability of claims and population data, providers will ultimately be able to use this information to better understand their patients’ needs and drive quality and performance metrics. The goal is for providers to understand a treatment’s cost and effectiveness to make better treatment decisions.Using data to guide the membership experience
Like most B-to-C companies, health plans are beginning to focus on their members as individuals rather than as a collective group. Like other consumers, members want to be seen and understood by their plan providers as individuals with unique strengths and challenges – and not as an ID number on a card.
This shift represents more than marketing and positioning. Health plans now capture massive volumes of data from member engagement, sales, and of course, health utilization that can be used to guide member experiences.
As devices like the Fitbit and various health apps take hold, health plans will have expanded access to their members’ wellness behavior patterns and to other levers that can promote healthy habits.
Artificial intelligence plays an essential role in shaping this individualized member experience. Chatbots, social media, web portals, and AI customer support will be able to provide plan selection, on-boarding, and benefits guidance that are entirely automated. Members can get questions answered without picking up the phone.
Members can be engaged wherever they are – through multiple channels – including phone apps, social media, health plan portals, and HR platforms at work. Member engagement is no longer seen as a one-time sign-up event but as ongoing touchpoints throughout the year.
With Baby Trax, ProgenyHealth has also adopted a highly individualized approach to member outreach. Baby Trax technology follows the infant from birth until year one. Each touchpoint is captured and leveraged through AI to guide the parents, providers, and the health plan on the treatment plan and resources needed for a successful journey.
COVID Trends – Telehealth is here to stay!
At the start of the pandemic, doctors and patients began to shift routine health visits to telehealth platforms. Initially used as a substitute for in-person care, a sizable portion of medical visits have continued online post-pandemic.
Last spring, New Hampshire’s Concord Hospital went from offering virtually zero telehealth services to 60% online almost overnight. Today, the pandemic need for telehealth has waned, but at Concord Hospital, virtual health still comprises about 16% of all appointments.
The need for infection isolation between doctor and patient is gone, yet telehealth will continue to provide critical access for patients who are homebound, live in nursing homes or prisons, live at rural distances, or need to see specialists outside of their region.
In 2020, Medicare made significant changes to its telehealth benefits. You can now get Medicare telehealth services:
- At renal dialysis facilities and at home,
- From home for certain emergency department visits,
- For certain physical and occupational therapy services at home,
- And for services delivered via audio-only devices.
A recent study found that 92% of pediatricians and clinicians believe telemedicine will remain part of their health practices in the future. In the study, virtually all the 787 pediatrician and clinician respondents reported using telemedicine.
“When it comes to virtual care, the focus should remain centered on ensuring technology is used to foster relationships and enhance the connection of patients with the care they trust,” said Dr. Mick Connors, co-founder and CEO of Anytime Pediatrics, which commissioned the study.
ProgenyHealth has engaged health plan members telephonically since our founding. As a result, we were uniquely positioned to offer services during the pandemic without missing a beat. We regularly score a 92% or better in member satisfaction surveys and maintain a 93 Client NPS score or better. Based on our 2020 experience, we will continue to broaden and enhance our member-facing technologies in the months ahead.
 Zachary Pruitt, et al. Population Health Management. Dec 2018