The healthcare industry is continuously evolving and regularly updating. Staying ahead of the curve, it becomes important for payers to always stay up to date to carry forward the treatment for patients. Whatever changes happen, there are two important things: regulating changes and advancing and navigating the recent healthcare change by taking the initiative. These areas not only shape the operational strategies of payers but also easily influence the overall quality of care for patients.
Recent regulatory changes in healthcare have introduced adjustments that payers should accept to compile and stay aligned. From new Medicaid and Medicare Updates, it is noted in the Affordable Care Act. Payers must understand the new updated rules and regulations to ensure they meet the legal requirements for optimizing their operations.
Health equity has emerged as a critical focus within the healthcare sector. These rules ensure that every individual should have fair treatment and should get patient access to care and overall healthcare services. Health equity initiatives aim to address health’s overall social status, decrease disparities, and improve Healthcare Accessibility to care for the whole population.
This blog will explore different regulations, the intersection of the regulatory changes in healthcare, and all the health equity initiatives. With an overall understanding of key areas, payers can easily navigate the current landscape and comply with the new regulations. According to the industry shift, fee-for-service to value-based care has been incorporated into health equity to upgrade the payment model. It helps patients receive better care.
Some points at a glance regarding Health Insurance Regulation
- High Priority for Health Equity: Over 80% of C-suite executives from life sciences and healthcare organizations consider improving health equity as an update for Healthcare Policy 2024
- Investment Plans: Nearly 50% of these executives plan to increase investments in health equity next year, according to surveys by the Deloitte Center for Health Solutions (2024 Outlook for Health Care and 2024 Outlook for Life Sciences).
- Value of Health Equity: Industry leaders recognize the value of providing high-quality healthcare to everyone.
- Short-term ROI: Achieving a return on investment (ROI) in health equity requires a strategic approach and time. Investing in health equity can improve competition in the short term by positively impacting recruitment, retention, and operations.
- Long-term Impact: In the long term, health equity investments can affect every aspect of a business, including workforce, products, and services. Health equity can drive value and growth.
- Business Imperative: Health equity should be a core leadership and organizational strategy component. Leaders in health equity play a crucial role in coordinating these efforts.
- Shift in Care: Health equity will become even more important as healthcare moves from reactive to restorative and preventive care.
5 Factors that influence health equity initiatives in 2024
Health equity is a fair opportunity for every patient who comes for treatment. It ensures this regardless of race, caste, gender, and ability. During the pandemic Covid-19, several cases did not work as per these rules, so most of the patients did not get the right treatment and were on time. Now, the U.S. healthcare system is changing. It has many care options, including virtual health, remote patient interaction, and more. Also, health insurance has a special community for LGBTQIA+ women’s health. It can help payers improve member health. Apart from equity regulation, it also focuses on the Affordable Healthcare Initiatives
Five Key Factors to Ensure Health Equity:
1. Life sciences companies integrate generative AI into their workflows. Healthcare leaders should ensure this technology does not create unintended biases. President Biden’s recent Executive Order on AI guides federal agencies on AI regulation. Over 80% of health equity leaders currently have little or no involvement in AI decision-making, which is expected to change. Leaders must apply a health equity lens to AI to avoid worsening disparities and maximize benefits.
2. Community Engagement and Clinical Trials. Sixty percent of health equity leaders aim to increase it. They plan to do this in 2024. They also prioritize collaboration. Building strong ties with community health centers can improve diversity in clinical trials. Forty-three percent of community health centers are conducting or interested in clinical trials. Addressing structural challenges can help realize this potential.
3. Nearly 40% of health equity leaders consider the workforce a big challenge. This includes recruitment, retention, and burnout. It is important to focus on employee health and well-being. It improves the overall retention process, reduces burnout, and boosts productivity. It is important to monitor all these through an equity lens.
4. Health equity leaders prioritize collaborating with key players. They do this to advance health equity. Public and private sector collaborations can drive value and growth through new engagements. Many CEOs globally have committed to health equity actions. Deloitte Global is a founding signer of the Zero Health Gaps Pledge.
5. Research is a priority for over half of health equity leaders (55%). They prioritize research in their strategies for 2024. Reliable data and accurate measurements are crucial. Strengthening data quality, community engagement, and multisectoral collaborations can facilitate key sector outcomes. Leaders face challenges. These include old data systems, standardization issues, and limited data sharing. Addressing these can enhance health equity research.
4 Regulatory Changes in Healthcare for Payers in 2024
1. Transparency in Coverage
Payers must provide cost-sharing information for all items and services by January 1, 2024. This requirement aims to make healthcare pricing transparent and consumer-friendly, allowing members to see their specific cost responsibilities and shop for services online.
Requirements:
- The Transparency in Coverage Act has expanded over the years, and it was initially announced in 2020.
- By January 2022, payers provided the overall pricing data on items and services included in-network and out-of-network.
- In 2023, CMS required payers to make the cost-sharing information accessible
2. Technical Challenges and Solutions
- Implementing transparency in coverage was technically challenging for many payers sometimes because of a lack of tools and access for the patients for the overall coverage.
- Modern core administrative processing systems (CAPS) like HealthRules® Payer utilized Healthy Edge’s APIs and tools, such as the Price Comparison Tool, to meet regulatory changes in healthcare requirements
- These advanced systems made it easier for payers to comply with transparency regulations.
- Making pricing data available in a consumer-friendly format poses challenges and opportunities in 2024.
Challenges:
- Ensuring the data is easy for everyday users to search and understand.
- We are providing accurate, real-time cost-sharing information for each member.
- It could confuse and frustrate members. This would lead to more calls to support centers and lower member satisfaction.
Opportunities:
- Payers can improve member engagement. They can enhance online shopping on their websites and member portals.
- We are informing members about missed screenings and vaccinations.
- Promoting healthy behaviors and encouraging member responsibilities, improves HEDIS scores and star ratings.
- HealthEdge products support portals. They provide real-time, personalized cost-sharing data. The data is specific to members’ benefit plans, benefits used, and selected providers.
3. Member Engagement and Satisfaction
- Accurate data presentation can prevent confusion and frustration among members.
- The integration of HealthRules Payer and HealthEdge Source ensures higher accuracy. It uses negotiated rates and claims data.
- Forward-thinking payers will leverage these opportunities to strengthen member engagement and improve satisfaction.
4. Advancing Interoperability and Improving Prior Authorization Processes
CMS’s proposed rule requires payers to use electronic prior authorization. They must also set data exchange standards. These changes make spreading health data smoother. It connects patients, providers, and payers. It will boost equality and ultimately reduce disruptions.
Healthcare Equity to Access the Care
CMS’s new framework is focused on reducing health disparities. It will collect comprehensive demographic data addressing healthcare access and overall outcome inequities. A payer must collect all detailed data that includes race, ethnicity, and overall social determinants of health. This will create a holistic record of members.
Changes in Star Ratings for Medicare Advantage Plans
CMS has updated how star ratings are calculated, emphasizing member experience more. These changes aim to improve care quality and patient satisfaction. They directly impact CMS bonuses and incentives for health plans. Payers can use advanced modeling to predict outcomes and make necessary adjustments.
Key Insights on healthcare equity regulations
- We surveyed 500 health equity leaders. They were from providers, payers, life sciences, government, and nonprofit organizations.
- 73% of respondents expect to prioritize health equity more over the next year.
- Most respondents foresee more investments in health equity. However, they see competing priorities as a major barrier to strategy execution.
- Health equity payers’ investments have provided measurable benefits to organizational bottom lines and the health outcomes of the populations served.
- The top priorities are health equity access, quality, and strategy development. They are the same as in 2023.
- The focus is shifting. It’s moving to address downstream outcomes without impacting upstream social factors.
- Annual revenue is a measure of an organization’s size. It is emerging as an indicator of the perceived maturity of health equity efforts. This highlights the role of resource availability in driving action.
Conclusion
When healthcare changes, payers must stay updated on the new regulations. When prioritized, the information is spread between payers and providers. It is equally distributed. In 2024, transparency and health equity will become the focus.
It simply means that each one of the patients should take advantage of the treatment equally. There should not be any bias, regardless of caste, race, gender, or any other factor. Payers can improve patient outcomes. They do this by focusing on key areas. These areas ensure compliance, which drives the organization’s growth. This rule will help the whole population. It will also strengthen the healthcare system by making it work for everyone.
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