Payer executives are keeping a close eye on artificial intelligence, drug costs, behavioral health and more in 2024.
The 26 leaders featured in this article, part of an ongoing series, are all speaking at Becker's 2024 payer roundtables. This includes our spring Payer Issues Roundtable, which is set for April 8-9, 2024, at the Hyatt Regency in Chicago. Some executives will also speak at our fall Payer Issues Roundtable, which is set for Nov. 11-12, 2024, at the Hyatt Regency in Chicago.
If you work at a health plan and would like to join as a speaker in April or November, contact Randi Haseman at rhaseman@beckershealthcare.com.
Question: What are the top one to two trends you're watching right now?
Allison Hofmann. National Vice President, Health System Division, Cigna Healthcare (Bloomfield, Conn.): At Cigna Healthcare we have long believed that the connection between body and mind is important as it relates to total health and its role in helping to lower healthcare costs and drive better health outcomes. In fact, we recently released new research conducted with The Economist on how our U.S. youth mental health crisis demands a community response. Our research confirms that teens and parents are still suffering from mental and behavioral health issues, and they are looking for help. In fact, nearly half (47%) of the 1,500 U.S. parents of teenagers ages 13 to 17 say their child is experiencing mental health challenges.
Yet, we learned parents face multiple barriers to supporting family mental health, such as:
- overcoming the stigma associated with behavioral health issues
- the complexities of the health care system
- accessing affordable, timely services
Additionally, we continue to advance our work focusing on vitality, including our latest research addressing the capacity of individuals across multiple dimensions. Mental health is one of the most significant drivers of vitality. We know that adults without significant mental health challenges are 10 times more likely to have high vitality. If you are an employer, this means higher engagement and higher productivity, lower turnover, and also lower medical costs. When it comes to tackling a challenging issue like mental health, we see clients are revisiting point solution, and we know that integrating our benefits – such as medical, pharmacy and behavioral – drives savings for employers and health plans and improves health engagement for customers.
Susan Beaton. Vice President Health Plan Strategy of Wellframe (Boston): Individualizing the member experience, at scale, is top of mind at Wellframe. We all know that the healthcare system is notoriously difficult to navigate. But if members can find all the information they need to manage their chronic conditions, all in one place, they'll feel empowered to take control of their health.
Danielle Brooks. Director of Quality Health Equity at AmeriHealth Caritas (Philadelphia): In 2023, health equity continued to expand and become more integrated into the United States' healthcare system. The trends I will follow in 2024 include maternal health equity, privacy protections, and reduction of bias in machine learning for data. Maternal disparities continue to impact the Black/African American populations, leading to disproportionate increases in death and poor outcomes for this community. Data privacy protections are also critically important to make sure that data that is sensitive and potentially discriminatory are held to the highest security standards. And as AI and machine learning continue to evolve, steps need to be taken to reduce bias in analytical and reporting outcomes.
Neel Butala, MD. Chief Medical Officer of HiLabs and Assistant Professor at the University of Colorado (Aurora): Overall, I continue to think that AI will continue to disrupt the healthcare industry, starting with making operations more efficient. Forward-thinking organizations will be able to readily incorporate new AI tools into existing workflows to process and analyze data rapidly, provided that the underlying data is good quality. I also think that FHIR APIs will have increasing adoption, which will permit greater data interoperability and greater use of clinical data at health plans, such as through adoption of digital quality measures.
Caroline Carney, MD. President of Behavioral Health and Chief Medical Officer of Magellan Health (Phoenix): I am watching utilization trends, especially those for partial hospital and residential services, and the process to approval for the use of new therapeutics (e.g., psilocybins) and novel pharmacological treatments for mental illness. Top of mind for me is what these both will mean in terms of quality and value in behavioral healthcare.
Jessica Chaudhary, MD. Medical Director at Carelon Behavioral Health (Indianapolis): The top trends I am following right now are a shifting focus on greater collaborative care and a greater emphasis on preventive care. Preventive care will include more screening for mental health concerns and a deeper understanding of the interplay of behavioral and medical conditions. As there is greater incorporation of digital technology and responsible AI, we will be able to move upstream in risk categories and offer even earlier intervention to avoid high risk and crisis situations and utilization of care at high levels.
Damanjeet Chaubey, MD. Vice President of Clinical Affairs at Clover Health (Nashville, Tenn.): The top two trends on my watch list are
1. AI in healthcare. We are witnessing rapid development of a new technology in healthcare without necessarily figuring out safety guardrails, reliability, new standards, or the true measure of impact. Can we truly regulate? Do we just figure out what works best at an individual organization? Does it stifle competition? Does it further deepen inequality in healthcare?
2. Care delivery models for chronic disease management at home. What is the right balance of a clinician's virtual home visits vis-a-vis in-person home visits that meets our quality standards, improves access, enhances patient experience and reduces predicted adverse events — we study and practice these principles.
Po Chou. CEO of EVMS Medical Group (Norfolk, Va.): The trends that we are watching are: 1) the integration of medicine by retailers such as CVS, Walmart, Amazon, Walgreens and others; and 2) private equity transactions in medicine/healthcare.
Hillary Galyean. Vice President, Enterprise Account Management of First Choice Health Network (Seattle):
- Effective ways to control medical trend, while collaborating with delivery systems
- Strategic approaches to weight loss drugs
Gen Gillespie. Co-Founder and Chief Revenue Officer of Belong Health (Philadelphia): I'm monitoring the new CMS proposed rule for Medicare, which if enacted would fundamentally change the sales and marketing landscape for MA plans to Medicare beneficiaries and when they can enroll in Medicare Advantage products.
I also continue to monitor the challenges the provider industry faces with staffing shortages and physician burnout. We are only seeing the beginning of the long-term challenges and fallout from changes in the healthcare workforce dynamics, which have always existed and only needed the burning match of COVID and the public health emergency to turn into a full-scale labor crisis.
Robert Groves, MD. Executive Vice President and Chief Medical Officer of Banner | Aetna (Phoenix):
- Trend No. 1 — Prior authorization transformation to clinical decision support
- Trend No. 2 — Democratization of healthcare knowledge/control
- Bonus trend — Social determinants of health from measure to manage
Ross Hoffman, MD. Chief Medical Officer of Pharmacy and Innovation at Centene (St. Louis): 1). Care delivery models to support the provider and delivery infrastructure gap concerning best practices in memory care: prevention, diagnosis, treatment, care journey, supportive care of patient and caretaker in later-stage disease.
2). Aligning specialist value creation and informatics with leading at-risk primary care practices.
Cy Huffman, MD. Vice President and Chief Population Health Officer of BlueCare Tennessee (Chattanooga): One trend that I am watching very closely: CMS plans to drive health equity through value-based payment models.
Michael Hunn. CEO of CalOptima Health (Orange, Calif.): Two trends that seem to be accelerating are physician retirements and timely access to specialists. As the physician workforce declines and patient needs increase, the delivery system will be further strained by longer wait times, thereby causing the acuity mix of patients to proportionally increase. As a health plan, at some point, there will be concerns over member access and network adequacy.
Michael Kobernick, MD. Senior Medical Director of Health Plan Business at BCBS Michigan (Detroit): GLP1s are an area of extensive discussion across our plan and with employers. To cover or not to cover, what are the appropriate prior authorization and renewal criteria, and how will we deal with the cost.
Hossam Mahmoud, MD. Regional Chief Medical Officer of Carelon Behavioral Health (Phoenix): Over the past year, we have seen an increased interest, as well as apprehension, regarding the role that machine learning and AI — be it described as artificial intelligence or augmented intelligence — may play in healthcare in the near future. On the one hand, there is excitement about different use cases for patients, providers and payers, and about the potential to improve quality of care, patient experience, provider experience or cost of care. On the other hand, there remain many unanswered questions about accepted use, including safety, applicability, security and ethical implementation. This combination of interest and apprehension is not uncommon with the introduction of newer technologies. It will be interesting to track the evolution and implementation of AI within healthcare in 2024 and beyond.
Mamata Majmundar, MD. Chief Medical Officer of Evry Health (Dallas): I'm examining the impact on various stakeholders with the recent changes in pharmacy reimbursement models, American Heart Association's proposed cardiovascular-kidney-metabolic syndrome guidelines, and the increased use of lifelong medications used for weight regulation. What's the balance between costly treatments and viable alternatives? Will this drive adoption of holistic care solutions such as precision medicine, food as medicine, the gut microbiome for lasting change? What can we do to spark motivation for change at the onset of early identification? There's much to observe in this arena with our focus directly on early consumer engagement to improve health outcomes and reduce long-term costs.
Heather O'Toole, MD. Chief Medical Officer of Select Health (Murray, Utah): Our primary trending focus lies within the pharmaceutical space, propelled by a confluence of escalating prices for both new and existing drugs, heightened demand, and a surge in high-dollar gene and cell therapies. Unfortunately, projections indicate a sustained upward trajectory, necessitating a comprehensive strategy surpassing the scope of health plans. Encouragingly, we have observed upward shifts in behavioral health trends, with more members actively seeking care for conditions such as depression and anxiety. However, we recognize that this area requires continued observation, particularly with regard to treatment facilities, and applied behavioral analyst therapies.
Stephen Parodi, MD. Executive Vice President, External Affairs, Communications and Brand at The Permanente Federation:
- The transition to value-based care, a model of care that Kaiser Permanente has long championed. Value-based care incentivizes physicians and health systems to prevent health problems before they start, while reining in costs through the rigorous application of evidence-based medicine. A key lesson learned during the COVID-19 pandemic was the need to shift to value-based models of care. As shelter-in-place orders caused in-person patient visits to brick-and-mortar health care facilities to plummet, that decline dealt a financial blow to many fee-for-service healthcare organizations, which are paid per patient visit, treatment, or test — regardless of a patient’s health outcome. By contrast, prepaid value-based health systems demonstrated that they are better positioned to respond to changing patient need and an evolving healthcare landscape. Because they are integrated, focused on seamless care coordination, and accountable for both quality and cost of care, these systems can leverage technologies in diverse ways to respond rapidly to market dynamics. These are some of the key reasons our nation needs to embrace more fully value-based models.
- The delivery of more advanced care into the home. With the consumerization of healthcare, patients increasingly want to be treated at home. Permanente physicians lead advanced care-at-home programs in Oregon, Washington, California and Georgia, and collaborate with skilled teams of nurses and other medical-support professionals to deliver a blend of in-person visits, telehealth services and remote monitoring. These programs deliver high-quality care to patients with serious conditions, such as hypertension, COPD (chronic obstructive pulmonary disease), and diabetes, which, with the support of technologies, supplies, and care coordination protocols, Kaiser Permanente can treat and manage in the patient’s home without a hospital admission. This program has also given us an opportunity to bridge some health equity gaps. For example, we've found a quarter of the people admitted to our care-at-home program in the Northwest are at the highest neighborhood deprivation index. Some of these people cannot afford an ambulance ride to the hospital. Through our program, we can surround them at home with the care they need.
Payam Parvinchiha, MD. Interim Chief Medical Officer of SCAN Health Plan (Long Beach, Calif.): Health plan mergers and medical group acquisitions.
Pleasant Radford. Health Equity Officer at UCare (Minneapolis): The top trends that I am following are climate change and geriatric care. Climate change has an adverse impact on the health and well-being of communities — it is important for us in the healthcare industry to combat the climate crisis and protect public health. Lastly, the U.S. population is aging and living longer, so it is critical for the healthcare industry to strengthen our geriatric care management and improve older adults' quality of life.
Krystal Revai Sodaitis, MD. Associate Chief Medical Officer of Health Alliance Medical Plans (Champaign, Ill.): Right now I am very closely following how artificial intelligence can be appropriately used in the healthcare setting. It seems as if every day a new application using AI comes out, but how many of these discuss how AI can augment what we do, not replace it? I'm much more focused these days on small language models and how to apply them in a healthcare setting. There is also a lot of disruption with the latest CMS rule. I think it's early to see how the new rule is going to impact our operations, but it is something I am keeping an eye on.
Shelley Turk. Divisional Senior Vice President of Illinois Health Care Delivery at Health Care Service Corp. (Chicago): I am watching coverage and data on weight loss drugs, surgery and mental health treatment associated with obesity very closely. As we explore strategies around better managing obesity, it is clear to me that a holistic approach overall with many different modalities of care is optimal. The starting point is helping to ensure that physicians are documenting obesity as a chronic condition, coding the right obesity diagnosis (e.g., severe obesity) and sharing information with patients about treatment options for long-term weight-loss. I think there is a burgeoning understanding that weight is more often a function of biology and chemistry than a lack of willpower, but because there is no silver bullet for this chronic condition, and because a very small percentage of the physicians in the United States are trained in obesity medicine, we are together at a disadvantage in unpacking how to tackle this difficult space that negatively impacts so many Americans. Having said that, I am confident that we have a significant role to play that can continue to help individuals who struggle with obesity and who want to access care to improve or eliminate comorbidities and, ultimately, live their best lives.
Chris Wasel. President of Marketing and Strategic Partnerships at Vantage Healthcare (Canton, Mass.): The future of telehealth, virtual care for health plans: Technology advances are providing a tremendous opportunity for physician practices to effectively care for higher acuity patients that reside in senior living communities. The increased use of telehealth and timely data through electronic record systems and remote monitoring coupled by onsite care allows practices to better manage patients in place reducing hospitalizations and reducing healthcare expenditures.
Pioneering value-based care: future successes and strategic insights: As a large physician practice serving patients in assisted living facilities, as well as other settings, we are experiencing higher acuity in senior living communities. The number of assisted living communities and demand continues to increase. The combination of these trends provides an opportunity to deliver an on-site primary care model that delivers improved care and financial results for practices and payers covering patients in these settings.
Michael Weber. Vice President of Sales, Client and Health Promotion Services at Dean Health Plan by Medica (Madison, Wis.): Among the themes we consistently hear, a few stand out:
- Mental health support: In the nearly 50 school districts we insure across Southern Wisconsin, students are dealing with issues such as anxiety while staff are often coping with burnout. As the health insurer for these districts, Dean Health Plan looks at how we can support our members, their families and students through resources and services from our community and provider partners. In the past, there were many questions about physical services offered; now it is mental health needs.
- Control costs: What can employers do to truly control costs? Can coordinated networks provide a solution/meeting the providers before the sale? Are employers willing to make the hard choices to have a coordinated versus a broad network?
- Access to primary care: Need to balance sales and retention with the ability for members to get the care they need. For example, we partner with SSM Health to welcome new members and connect them to primary care.
Darren Wethers, MD. Chief Medical Officer of Atrio Health Plans (Salem, Ore.): Two trends have been notable for us. First is a shift in types of cancer diagnoses we are seeing. Breast and prostate cancer diagnoses have decreased, while skin, uterine and colon cancer diagnosis rates have increased compared to the prior year. I suspect that all those changes may reflect additional screening efforts made by the plan over the past few years, with cases identified earlier in evolution, where intervention opportunities are greater.
The second trend relates to the types of new members joining the plan: more of them are coming to Atrio from commercial plans, without prior Medicare Advantage history. As such their conditions and health needs are unknown to us, and we must devote additional resources to successfully onboard them. Getting them aligned with network providers is a high priority, as is ensuring alignment with our drug formulary.