Payers Will Improve Virtual Care, Forecasting, Growth in 2021

December 16, 2020 - Payers and stakeholder collaborators have the opportunity to rebuild the healthcare system into a more effective and consumer-centric system in 2021 by honing virtual care and other strategies, according to a new report released by PricewaterhouseCoopers’ Health Research Institute (HRI).

HRI interviewed executives from across the healthcare industry and conducted an online consumer survey during September 2020 as well as an online health executive survey from late August to mid-September 2020.

The consumer survey garnered over 2,500 responses and the executive survey received replies from 128 payers, 153 providers, and 124 pharmaceutical and life sciences executives.

“Nearly overnight, as volumes dropped precipitously, the deadly pandemic thrust patients, doctors, pharmaceutical companies and payers headfirst onto virtual platforms and other digital technologies that many had previously approached with hesitation,” HRI summarized.

“The sudden experiment allowed for valuable insights that health organizations in 2021 can use to fine-tune where they should land on the spectrum of virtual and in-person—in ways that make the most sense for care delivery, patient experience, reimbursement and clinical research. The insights also can help healthcare organizations navigate vaccine distribution as well as the ebbs and flows of patient volumes due to COVID-19 in the year ahead.”

In particular, payers have the chance to rethink virtual care and healthcare forecasting as well as take advantage of growth opportunities, the report found.

Virtual care

After the record-setting virtual care utilization in 2020, payers still face questions around how to reimburse for telehealth and virtual care visits and how to hone those care modalities.

“What we have found since COVID is that, when telehealth went mainstream, the expectations went way up,” Mike Thompson told HealthPayerIntelligence in a previous interview regarding the future of telehealth. “As we go forward, I think it becomes more of an integrated strategy. It becomes an expectation that this is a modality that providers will use.”

More than nine in ten provider participants in the HRI survey were using telehealth for primary care services (92 percent), specifically follow-up appointments (68 percent). Some also used it for ongoing care management.

While the pandemic emphasized the many advantages of telehealth and virtual care, payers and the healthcare system as a whole also had to confront certain hurdles associated with these care delivery models.

Although in 2020 telehealth reached many patient populations that formerly would not have accessed it, the report revealed continued disparities in consumer experience of virtual care and telehealth. In particular, Black patients and Latinx patients were more likely to experience technical problems and stated that the follow-up steps after the call were unclear.

Providers also faced difficulties with the transition to virtual care and telehealth. Specifically, the pandemic brought virtual care and telehealth reimbursement disputes to the forefront.

Over half of health service provider executive interviewees found reimbursement to be a “very significant” challenge for their telehealth programs.

Indeed, in an Avalere survey, payers cited both telehealth technology access and reimbursement as two of their major coronavirus-related telehealth concerns.

This issue has received extensive coverage. In fact, the HRI report indicated that reimbursement issues might be distracting payers from listening to the member and provider experiences in telehealth.

Nearly four in ten healthcare provider participants (37 percent) stated that consumer willingness to use telehealth was a hurdle to rolling out their virtual care plan while 18 percent said provider willingness stood in the way.

If payers overlook these reticent populations as they focus their efforts on reconciling reimbursement, their telehealth, and virtual care strategies may not be as effective.

The report recommended using care coordination to resolve reimbursement barriers.

Payers should also be aware that provider satisfaction is essential to strong virtual care and should streamline processes for telehealth visits including visits involving more than one provider.

Additionally, the report emphasized that payers and providers should consciously avoid compounding existing inequities and creating new ones through virtual care. To accomplish this, payers can partner with community-based organizations and relevant companies to expand access to telehealth technologies.

Centene, for example, is delivering the technology to community members by providing smartphones for rural communities, HRI explained.

Scalability and financial stability of virtual care are two challenges for which payers and providers need to formulate long-term strategies, HRI added. Now is an optimal time to plan for the future.

The experts also recommended that health plans consider the impact of their virtual care strategies on local providers. In particular, payers should avoid further fragmentation of the healthcare system through these digital care delivery methods.

Payers can also find ways to leverage healthcare technology and streamline digital processes to ease provider burden.

Healthcare forecasting

When the pandemic hit the US in early 2020, it quickly became clear that attempting to make projections about 2021 would be challenging.

This has not stopped healthcare leaders from trying. Nearly three-quarters of the health executive participants (74 percent) said that they would increase investments in predictive modeling in the new year.

Payers specifically would benefit from better insights into market churn between Medicaid,  Medicare, and commercial insurance. They could also aim for more comprehensive projections into utilization fluctuations and medical loss ratio impact.

However, HRI stressed that the responsibility does not rest entirely on payers to construct such prediction capabilities—in fact, it cannot rest solely on them.

“No one organization holds all the data needed to paint a full picture of the future,” the report stated.

Healthcare leaders have taken the hint. Over seven in ten executives told HRI that they were looking to collaborate or had already started collaborating with other providers and payers and 65 percent were engaging or planning to engage with public health agencies.

A few strategies can aid this endeavor to form better projections.

First, new interoperability regulations could ease the process as organizations can more easily share data to piece together an accurate depiction of the current healthcare environment.

These regulations have been received warily by the healthcare industry, largely due to data security concerns. However, HRI said that payers and other stakeholders can protect their data and serve consumers simultaneously under the new regulations. Consumer education and trust will be key. Payers will also want to partner with proven, reputable organizations.

“A comprehensive strategy that considers how the rules can lead to a more effective healthcare system that puts the consumer in the center would put the organization on offense in this new data-sharing environment,” HRI stated.

Second, focusing on real-time information instead of historical trends and past claims data can help organizations identify crises earlier.

Third, leveraging real-time data can drive proactive monitoring of members’ chronic conditions to better predict their needs and communicate with them in a more timely manner.

Finally, forming regional collaborations between academic medical centers, community-based organizations, government agencies, employers, and other stakeholders will ensure a more comprehensive approach to healthcare.

Growth opportunities

In 2020, payers faced public outrage over their increased profits during the pandemic.

The accusation was not without merit: in the second quarter, nearly 25 percent of payers had an 800 percent risk-based capital ratio—four times the minimum that states typically mandate for payers. On average, payers’ risk-based capital ratio grew from 616 percent in 2019 to 690 in the second quarter of 2020.

HRI urged payers to invest these profits for a couple of reasons, not the least of which being to escape further censure from the public. States might also force health plans to invest those profits if they do not do so of their own accord.

Virtual care is a prime outlet for these profits, HRI recommended. In particular, payers may choose to expand into specialties, demographics, and regions that need remote care. Payers can also acquire or ally with providers and extend their virtual access to such groups.

Investment in member experience will be key to success in 2021. Many payers have already recognized this. Nearly half of the payer executive participants said that they would be investing in member experience through digital product support and educational mobile apps or other technologies.

Payers’ extra cash may also fuel new value-based contracts with providers. Due to the dive in fee-for-service revenue during the pandemic, providers may be more open to diversifying their revenue streams. This could be the perfect time to drive a faster transition to value-based care.

After a grueling year for the nation, 2021 promises the opportunity not only to rebuild but to improve upon the old normal in healthcare.