The COVID-19 pandemic caught the healthcare industry totally off guard when it first hit the world. As providers and payers gradually adapted to the new normal, customers chose to seek a personalized experience like never before. In the post-pandemic world, the insurance companies that are preparing to focus on new clinical and quality-driven expertise and services will have an edge in meeting customers’ expectations. This would lead to a tectonic shift toward consumerism in healthcare.
Payers made record profits in 2020 owing to lower elective procedures and postponed routine care. But this also meant payers couldn’t reach the minimum standards set by the ACA for medical loss ratios (MLR). According to CMS data, more than 11.2 million people qualified for $2.5 billion in MLR rebates from health insurers in 2020. A Kaiser Family Foundation report estimates that 2021 rebates will total $2.1 billion for 10.8 million members.
In 2021 and beyond, payers can utilize the new normal and assume a consumer- and quality-centric role. Let’s have a look at the Top 5 trends for health plans to watch in 2021.
1. Jump in Elective Procedures
Elective procedures saw a steep fall last year after the COVID-19 pandemic gripped the country and the rest of the world. The trend is on course for change in 2021 as the utilization of healthcare services is expected to bounce back and jump by up to 10 percent. According to a paper published by KPMG, as of October 2020, specialty physicians such as dermatologists and urologists, as well as adult primary care physicians, were exceeding their pre-pandemic baselines. However, pulmonologists and behavioral health provider visits were substantially below their baselines. Age is also expected to play a vital role in the rebound. Once the pandemic eases, elderly patients may not wait as long as the younger ones to reschedule their pending elective procedures. This will have a direct bearing on spending by commercially insured and Medicare members. This calls for adopting a more consumer-centric approach by payers by engaging with members. Payers can guide their members on whether to put off the procedure further or go for it without any more delay.
2. Unemployment-driven Enrolment Shifts
A high number of cancelled elective procedures and routine care in 2020 ensured minimal impact of the pandemic on payers as healthcare utilization and claims activity hit a record low. On the other side, the pandemic rendered many people jobless as a result of which the employer-sponsored insurance (ESI) coverage number fell drastically. As more people turn to the Affordable Care Act Exchanges and Medicaid, payers this year are expected to focus more on the evolving needs of individuals and families within their marketplaces. Providing additional education and outreach opportunities regarding current on-exchange, Medicaid, and Medicare product offerings, as well as how to transition between products as life circumstances warrant is expected to the agenda of payers. The paper said payers will want to gain some certainty around member churn as the economy fluctuates. To this end, data analytics can help predict patterns of migration between employer-sponsored health plans, the Exchanges, Medicaid, and Medicare, and, thereby, help with risk prediction to protect medical loss ratios.
3. Increased Audit of Government Products
Payers may have to face additional supervision and audit owing to an expansion into federally facilitated marketplace exchanges and other government plans. The potential audit areas, the paper said, could include Federal Market Conduct Examinations, FFE Compliance Reviews, audits of Medicare Parts C and D organizational/coverage determinations, appeals and grievances, as well as Part D formulary and benefit administration. Increased scrutiny would give the companies an opportunity to help members in ensuring that supporting documentation of procedures and processes are up to date and that methods of assessing new regulations, updating policies, and informing stakeholders are in place.
4. Greater Role and Importance of Telehealth
The pandemic gave a major push to telehealth services as patients opted for a safe environment at home for a consultation, testing and treatment of their respective illnesses. Remote care got further boost as public health insurance programs were required to cover and reimburse for telehealth services no matter where it was received. We all know that telehealth is here to stay. Considering this, multiple states expanded telehealth in Medicaid programs, relaxing restrictions around provider licensing and online prescribing. The paper said that private insurers that followed this path during the pandemic reported a 4,000 percent increase in claims from the previous year. The importance and role of remote care is only going to increase, which calls for working closely with the governments on regulations that ensure widespread access to telehealth as well as appropriate levels of payment and reimbursement.
5. Spotlight on Health Equity
For years, health insurance providers have been committed to improving health equity and combating social determinants of health in communities. Bringing discrimination and systemic racism to an end is essential for an equitable health care system. With pandemic still around, 2021 may be the year when access to health and wellness is available to all irrespective of racial and socioeconomic status through programs curated to promote health equity. This is where payers will have a significant role to play in member engagement. The paper points out how given the widespread concerns about mental health, many health plans are using data analytics to target patients in need with offers of more robust mental health benefits. For those members concerned about their underlying medical conditions and overall ability to ward off illness, health plans can offer incentives for meeting self-care goals or for using wearable technologies to monitor their health.
Conclusion: The health plan sector is set for a big haul in 2021 and years to come. Consumer engagement and high-quality service will take precedent as demand for elective procedures is poised to surge. Customers will also expect new products through federal exchanges. The priority list for payers must include continuity of care, fostering wellness, and advancement of value-based care.
