Electronic Health Reporter

By Abhinav Shashank, president, Innovaccer.

The health plan market is undergoing a drastic transformation. In the past, the competition had been lean with just a small number of payers. However, the market dynamics are changing. Since 2017, the number of MA plan choices per county has increased by 49%. The competition is said to grow even more in the coming years as more health plans are set to enter the market, owing to the fact that nearly 26 million baby boomers will age into Medicare through 2030.

Rising cost burden on health plans

With additional members, the “paperwork” and administrative costs are also increasing. A recent report revealed that there was almost a 6% increase in administrative expenses for MCOs in 2017. The substantial rise in membership with soaring costs means many health plans might find themselves in a financially untenable situation.

Along with the growing administrative burden, the compliance requirements are also weighing on the workload and costs. The push towards improving accuracy, completeness, and timeliness of the data is intensifying to “ensure that provider claims for actual health care spending matches the health plans reported financially,” said Seema Verma. To fulfill the reporting requirements and avoid financial penalties, health plans will have to improve their data submission process to align with the specific rules, formats, and regulations of a given state, which also ensures an increase in cost.

Payers don’t have much control or influence on the administrative and compliance costs. The member population will increase, and so will the requisites by regulatory authorities. The costs are likely to keep increasing on these fronts in the future.

The growing financial pressure has made it inevitable for payers to explore measures to contain costs from spiraling out of control. Since operations account for around 50% of an insurer’s base cost, reducing expenses on this segment can result in cost savings of significant proportions.

Resolution for cost pressures: Operational efficiency

There are certain operational activities such as claims adjudication, reprocessing, and post-call documentation which are highly repeatable and are executed manually. With the addition of more members each year, the burden of these tasks ought to grow even more. Automating these tasks can give a significant boost to operational efficiency; at the same time, it can help reduce overall costs. According to an article, automation technology can lead to an additional operational cost savings of up to 30 percent within five years for many payers.

Outcomes of automating operational activities 

Apart from cost savings and reduced utilization, automating operational tasks has multiple other advantages. Automating routine tasks can ensure that the tasks that previously took days to finish are completed in minutes. The accelerated service delivery can build more synergy between members, providers, and internal stakeholders.

Automation technology can operate 24/7 and can be scaled up or down with demand. It provides a lot of flexibility that wasn’t available before. By creating room for more capacity (with flexibility), automation provides the necessary capabilities for payers to remain competitive. Not to mention, the automation reduces the scope of manual errors, resulting in efficient documentation, network performance tracking, and reduced coding and care gaps.

The challenge in implementing automation

There are hardly any disadvantages of embracing automation; however, implementing the technology is a challenge.

The core systems that most payers use cannot be easily modified. For effective deployment of automation, it is important to standardize and integrate the data and workflows that span across multiple disconnected systems. Quite often, payers don’t have the technological capabilities to support data standardization and require duplicative manual data entry to fulfill the task.

Fragmented data is the reason behind increasing IT costs and subsequently rising operating costs. Unstructured data prohibits health plans from leveraging new technologies and venturing into fresh business opportunities. The complicated legacy IT landscape prevents payers from building better collaboration in their network, which has considerable negative implications on their operational efficiency.

Standardizing patient data

Payers can streamline the data through a data platform and make it usable for other digital platforms. A data platform can clean and aggregate healthcare data from sources, including electronic health records, claims, pharmacies, hospitals, labs, and so on. This is a quick and inexpensive way to enjoy the benefits of automating operational activities without undertaking major core system transformations.

Apart from data aggregation, a data platform can also provide some relevant and useful information. By leveraging artificial intelligence and rich analytical capabilities, it can offer dashboard views, custom insights, and decision support that can reveal the existing coding and care gaps. Not only will this information help payers to improve care delivery and member experience, but it will also reduce unnecessary utilization of resources, and thereby the expenses. 

Road ahead

The cost pressures are not likely to reduce anytime soon; if anything, they are only going to grow. Apart from compliance, competition, and administration, several other factors are going to add fuel to the growing expenses like price transparency, customer cost-consciousness, and regulatory changes, to name a few.

The new group of players populating the payer market must be equipped with the right technology infrastructure and operational capabilities to demonstrate efficient cost management for long-term survival. However, according to a report, a lot of payers still feel they don’t have the resources in place to become a “data-driven” organization.

Containing costs is emerging as a significant factor in gaining a competitive advantage. Payers who are quick to embrace technologies that deliver substantial cost savings will be able to achieve stellar performance.