healthcaretechoutlook

2021 Predictions – CMS Changes, Health Plans and the COVID Effect

Steve Wigginton, CEO, Icario, IcarioSteve Wigginton, CEO, Icario
Below are insights from Icario CEO Steve Wigginton outlining his thoughts on CMS changes, opportunities for health plans and the COVID effect for the coming year.

CMS changes magnify the importance of member experience and satisfaction measures. As a result of the COVID-19 pandemic, CMS temporarily relaxed some of its quality measure reporting requirements and expanded options for accessing care to account for the decrease in healthcare utilization. Health action has been fundamental to driving these measures and a health plan's quality and financial performance. Concurrently, CMS has magnified the focus on, and importance of, member experience and satisfaction through significant changes to the Stars Rating – with member satisfaction and experience accounting for 40% of Star Ratings going forward. Medicaid has similarly shifted its focus and attention toward member satisfaction and experience by tying incentives and favorable auto assignment to these measures. Health plans that succeed under these new performance measures will be those that make investments and reallocate budget to focus on driving consumer engagement and action to build member loyalty and affinity, while coordinating their many member touchpoints to optimize each interactions’ value.

Health plans play a pivotal role in supporting unanticipated and emerging healthcare demands. COVID-19 has exacerbated an existing mental health endemic. It has also reinforced the importance and criticality of vaccinations. Mental health access through telehealth has, almost overnight, become universal, allowing remote access and reimbursement within a framework that has traditionally been delivered exclusively in-person. Yet trial and uptake of these new modalities remains low. The development of COVID-19 vaccines offer hope for controlling the pandemic, yet attitudes towards vaccination have been on the decline. Health plans have a unique opportunity to drive awareness, education and adoption of new modalities, treatments and vaccines through highly personalized, impactful engagement with their members. Those that do it best will deliver superior health outcomes and secure a trusted relationship with their members.

Health plans recognize the need for personalized communications. The largest opportunity to impact healthcare outcomes and member satisfaction is through personalization. Unlike consumer-focused business, healthcare has been slow to adopt the kinds of technology-enabled one-to-one communication practices that power the world’s most trusted consumer brands.
AI and machine learning, coupled with the ubiquity of text/app/Web channels, create opportunities for a unique and innovative communication framework that produces health action results akin to the non-healthcare setting. Through personalization, health plans can appropriate emerging opportunities and bridge existing barriers to health action which have been historically difficult to influence. Health plans that can personalize their member relationships will improve member satisfaction and health outcomes, both of which are accretive to the health plan’s bottom line.

The COVID effect.

COVID has created both a financial and a healthcare crisis. First, with the layoffs, business closures, and downsizing more individuals are becoming eligible for Medicaid and subsidized exchange plans. Since February, Medicaid has added 6M eligible individuals; and this number continues to grow and will for the foreseeable future. However, plans have unintuitively experienced significant declines in their medical loss ratio corresponding to a dramatic decrease in healthcare utilization. This decline will be short-lived with more individuals beginning to access care for deferred services and will likely cause a sharp swing in a rising MLR with the pent-up demand put off until this year.

Second, with the increase in Medicare and previously described Medicaid eligibles, health plans are seeing a sharp increase in dual-eligibles enrollment in Special Needs Plans. This is a top focus for leading health plans since, when properly managed, Special Needs Plans provide a solid financial model for delivering a sustainable benefit product. States, through sub regulatory measures, are also encouraging SNP enrollment through financial alignment initiatives.

Last, COVID and the significant 2020 social unrest magnified the racial disparities in healthcare. As a percent of the population, more brown and black individuals tested COVID positive with a concern that a large portion of individuals are in pharmacy deserts where there is greater difficulty in getting a vaccination. As a result, some health systems are standing up efforts to address and bridge the divide to provide access to services, programs and technology enabling greater access to care. However, with healthcare beginning to make a more intentional effort to bridge these divides, initiatives are still immature and 2021 will hopefully fast forward needed change to equalize access.

In a dark and solemn period during World War II, Winston Churchill said “never let a good crisis go to waste.” In a similar vein, the healthcare industry has responded to this monumental and unforeseen crisis with innovation that will persist far beyond COVID-19. This period has amplified and reinforced the need to engage people in personalized ways to influence health action behavior (whether vaccinations, screenings, or other services) that is not only critical to an individual’s own care, but also to the health and well-being of our communities. There is reason to be optimistic that the industry will continue to deploy unique and innovative approaches to capitalize on the transformation and innovation opportunities the pandemic has accelerated.
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