Artificial intelligence, progress in health equity and innovations in value-based care will drive change in the payer space in the next decade, industry leaders told Becker's.
The executives featured in this article are all speaking at the Becker's Payer Issues Roundtable, which will take place Nov. 9-10 at the Swissotel in Chicago.
To learn more about this event, click here. If you would like to join as a speaker, contact Randi Haseman at rhaseman@beckershealthcare.com.
Note: Responses have been lightly edited for length and clarity.
Question: What will change in the payer industry in the next 10 years?
Don Antonucci. President and CEO of Providence Health Plan (Portland, Ore.): Over the next decade I believe that the number of value-based care agreements will dramatically increase as payers continue to look for ways to affect better patient outcomes, improve quality and provide affordable coverage and care. Along those same lines, as demand for better patient experiences increases, I believe we will see an industry shift toward more collaborative care models to ensure tighter integration of care and better data sharing. Finally, I predict more payers will lean into community partners and organizations as a means of positively impacting social determinants of health to improve population outcomes and overall health equity.
John Bulger, DO. Chief Medical Officer of Geisinger Health Plan (Danville, Pa.): I expect to see more consolidation within all sectors of the payer industry in the coming years. There will also be more focus on the consumer and digitizing the consumer experience. This will include members, employers, physicians and other providers, and brokers as consumers. The goal of all of this should be to create value for the member which in turn will create value for other stakeholders.
Neel Butala, MD. Assistant Professor of Medicine-Cardiology at the University of Colorado School of Medicine (Aurora); Chief Medical Officer of HiLabs: I think the democratization of advanced analytics and AI, combined with increasing data interoperability, will dramatically change the payer industry in the next 10 years. Payers can leverage AI to transform everything from back-office operations to prior authorization to care management. However, the true impact of AI at each payer will depend heavily on the availability of good quality data to feed into their models. Fortunately, I think foresighted payers can apply the same AI and advanced analytics capabilities upstream to tackle data quality issues upfront, which will be of increasing importance as payers compete to use these newer technologies.
Ceci Connolly. President and CEO at Alliance of Community Health Plans (Washington, D.C.): There are many exciting changes just over the horizon that will impact the payer industry and the way that consumers receive care. In the wake of the COVID-19 pandemic, we have seen a dramatic rise in what we call Care Anywhere, including telehealth, remote monitoring and hospital-at-home, allowing consumers access to high-quality care right where they are. Artificial intelligence has the potential to streamline care delivery, cut down on costs and keep patients healthier longer. Those new frontiers will of course come with complex, even controversial questions. With 10,000 additional Americans qualifying for Medicare each day, we at ACHP are hopeful that many of our smart policy recommendations in MA for Tomorrow will have long been enacted by 2033, paving the way for affordable, high-quality care for generations of seniors to come.
Mac Davis. Vice President, Digital Product and Data of Belong Health (Philadelphia): We know scale gives payers a variety of competitive advantages, from lower administrative costs per member to membership density that incentivizes higher levels of collaboration with providers. We've already seen and will continue to see considerable consolidation in the market as plans look to take advantage of scale and tighten vertical operational alignment.
Local and regional payers are looking at new ways to compete with payers that have achieved scale to continue serving the communities they know like the back of their hands. The next 10 years look bright. Whether it is launching new products like D-SNPs, intelligently using ML/AI to gain operational efficiencies previously only available to those with scale, or finding new ways to drive improved provider and CBO network performance, local and regional plans have more tools in their toolbox to gain the upper hand in their markets than they did in the last decade.
Tenbit Emiru, MD, PhD. Executive Vice President and Chief Medical Officer of UCare (Minneapolis): AI capabilities, robotic process automation and machine learning tools will change the payer industry in the next 10 years. Significant advances in technology to diagnose, interpret tests, provide treatment and other supportive services for members have been made in just the last few years. More is anticipated in areas of interactive member engagement, use of augmented reality in treatment and therapy, AI in health coaching programs, home-based monitoring and other services such as virtual assistants to support members receive care and live healthily longer in their homes and communities. Several functions such as mining clinical data to make meaningful advances in population health, predicting risks and claims processing will look and feel different in 10 years. These technological advances have been in place to varying degrees in healthcare and are becoming faster and more accurate. In the next 10 years, we will be farther along in incorporating AI and automation in the industry by leaps and bounds. The key will be figuring out how to use technology in a way that is equitable, ethical and free of bias. As UCare implements these improvements, we will be mindful to balance them with the personalized, human interactions and individualized services our members expect from us.
Natasha Khouri. Associate Vice President, Digital Health Strategy & Solutions at UPMC Health Plan (Pittsburgh): The key trends that I think will be most impactful on our industry over the next 10 years: progressive requirements around data interoperability, an accelerated march towards value-based contracts, and greater application of AI in healthcare. These are all dynamics that will have outsized impact on our industry, because they flip underlying paradigms that have defined the relationships between healthcare stakeholders and in many ways held back progress. I'm hopeful these trends will unlock greater collaboration between payers and providers, greater personalization and patient-centered care models, a more efficient application of healthcare resources, and ultimately improve population health outcomes. My hope is also that the push, particularly coming from the public sector, to be accountable on health equity, will deliver universally better, more equitable outcomes for everyone over the next 10 years.
Matthew McGinnis. Vice President, Data and Analytics Strategy at Evernorth (St. Louis): The pandemic accelerated innovation across the healthcare industry around how and where people can get care, but the reality is that access to care continues to be a challenge for many people in our country. To solve this issue, payers will need to embrace digital and virtual care options to meet their customers where they are, giving them access to convenient and affordable care, across medical, behavioral, pharmacy and other services. This shift will in turn create new and greater data that if leveraged appropriately, will enable more coordinated and seamless care for customers and patients.
Doug Nemecek, MD. Chief Medical Officer, Behavioral Health at Evernorth Health Services (St. Louis): It's exciting to think about the innovation we will see across the healthcare industry in the next decade. Digital care and health technology continue to create new opportunities for individuals to access care when and where they need it. It also creates new ways for payers to partner with providers to help improve the fragmentation across healthcare, and across an individual's team of providers. Specific to behavioral health, we'll see more measurement-based care which will allow us to match our patients with care that will best meet their individual needs. The amount of innovation and technological advancements we've seen in the last few years is just a preview of the acceleration we can expect over the next 10.
J. Nwando Olayiwola, MD. Chief Health Equity Officer and Senior Vice President at Humana (Louisville, Ky.): I believe Humana, and all payers, will continue to influence and enable a more equitable healthcare ecosystem over the next 10 years and beyond. To continue to ensure every person has the opportunity to reach their full health potential, payers must ensure health equity stays central to healthcare, guided by appropriate data collection and disaggregation, centering the voices and experiences of the most marginalized, and improving access to the highest quality of care for all through unlocking the potential of value-based care. Payers will double down on efforts to achieve holistic health for every patient — physically, mentally, emotionally and socially, putting real people and real patients at the center of health and healthcare, and within a community context.
Kimberly Reich. Privacy and Compliance Officer at Lake County Physicians' Association (Gurnee, Ill.): In October, 2021 the CMS Innovation Center released its "Innovation Center Strategy Refresh" which summarizes CMMI's lessons learned after its first decade of operation and launching over 50 model tests.
CMMI has identified five strategic directives they expect will define and drive healthcare and the payer industry over the next decade:
- Drive Accountable Care: Give all participating providers the incentives and tools to deliver high-quality, coordinated, team-based care that promotes health, thereby reducing fragmentation and costs for people and the health system.
- Advance Health Equity: Embed health equity in every aspect of CMMI models. New models will require participants to collect and report the demographic data of their beneficiaries and, as appropriate, data on social needs and social determinants of health.
- Support Care Innovations: Leverage a range of supports that enable integrated, person-centered care such as actionable, practice-specific data, technology, dissemination of best practices, peer-to-peer learning collaboratives, and payment flexibilities. All models will consider or include patient-reported outcomes as part of the performance measurement strategy.
- Improve Access by Addressing Affordability: Pursue strategies to address health care prices, affordability, and reduce unnecessary or duplicative care. Set targets to reduce the percentage of beneficiaries that forgo care due to cost by 2030. All models will consider and include opportunities to improve affordability of high-value care by beneficiaries.
- Partner to Achieve System Transformation: Align priorities and policies across CMS and aggressively engage payers, purchasers, providers, states, and beneficiaries to improve quality, to achieve equitable outcomes, and to reduce health care costs. Where applicable, all new models will make multi-payer alignment available by 2030. All new models will collect and integrate patient perspectives across the life cycle.
Bruce Rogen, MD. Chief Medical Officer of Cleveland Clinic Employee Health Plan:
- Global capitation with scaled up consolidated clinically integrated networks extending across large geographic areas due to continued provider system mergers and acquisitions (à la Kaiser-Geisinger.)
- Population health improvements based on global capitation payments leading to cost efficiency and quality improvement with less waste in the system, dependent on large scale data aggregations and integration with longitudinal patient records combining information across provider networks and payers claims sources.
- Better data sharing and capitation leading to more trust between providers and payers, which then leads to more integration across the industry, including authorizations and approvals in near real time (hours rather than days) due to two-way communication between EMRs and payer systems.
Anil Singh, MD. Senior Vice President and Executive Medical Director, Population and Curated Health of Highmark Health (Pittsburgh): Payers need to start thinking about how to put the "health" back in health plans. At Highmark Health, we're hyper-focused on a holistic approach to health, rather than just treating illness. By creating personalized journeys that suit each member's needs, it's easier to engage in and take the right steps to manage care — which ultimately improves health outcomes and overall population health.
Ashish Shah. CEO at Dina (Chicago): We'll see three major trends that will help payers deliver an amazing member experience. First, payers will prioritize the home as a primary site of care and invest in the tools, services and partners to completely build out that capability beyond traditional home care. Second, payers will invest in personal concierge services (similar to the hospitality industry) to deliver a highly coordinated, high-quality 5-star experience for their members. And third, payers will make available a suite of both medical and non-medical benefits and actually promote the healthy utilization of them because they will reduce costs and improve quality/experience. There will be hard data available that proves this out and will lead to a more permanent benefit structure that includes food, housing, personal care, etc.
Michael Todaro, PharmD. Chief Operating Officer of Magnolia Health (Ridgeland, Miss.): We are keeping a very close eye on emerging AI technology, and how it can be used to augment repetitive tasks as well as harness the ability for predictive analytics to better guide our care management teams. Healthcare is merely scratching the surface of mechanisms to put AI to work for us to improve customer service, reduce fraud, waste, and abuse and reduce overall costs.
Howard Weiss. Vice President of Public Policy and Government Engagement of EmblemHealth (New York City): Regulators are demanding payers be more transparent in their pricing and administrative procedures. These demands are likely to intensify, and it is possible plans may soon need to comply with nationally standardized processes on everything from credentialing to the list of services that may be subject to utilization management. More standardization and price transparency will make it difficult for payers to differentiate themselves on cost. Instead, payers, including health plans, will be judged on their ability to work with providers to reduce health disparities and effectively manage chronic conditions through value-based arrangements. Payers that are most aligned with provider groups that are willing to take financial risk based on their performance will be better situated to succeed in this environment.
Chanin Wendling. Senior Director of Clinical Operations at Contigo Health (Charlotte, N.C.): We expect that more health systems will launch health plans, for at least their domestic markets, becoming both providers and payers of care. That will allow them to better balance overall finances to improve focus on preventive care, outreach, and care at home. These programs can reduce revenue on the provider side but that can be offset by a reduction in claims on the payer side. We also expect continued disruption of the healthcare system by employers, with more direct partnerships between employers and health systems to drive better outcomes and reduce costs.
Darren Wethers, MD. Chief Medical Officer of Atrio Health Plans (Salem, Ore.): In the future, there will be standardization of prior authorization practices for health plans. In Arizona, providers must submit prior authorization requests for procedures, services and medications on state-standardized forms (which Sue Ewing, PharmD, and I helped craft); all commercial health plans are obligated to accept these forms in lieu of their own proprietary ones. Medicare has begun discussing requiring more transparency toward which criteria are being used by Medicare Advantage plans, in addition to National Coverage Determinations Local Coverage Determinations and Local Coverage Articles; use of a standard interface for prior authorization called a Fast Healthcare Interoperability Resources application programming interface as also been proposed. These reforms should relieve some administrative burden on physicians and lead to greater efficiency in the authorization process.
Cameual Wright, MD. Vice President and Market Chief Medical Officer of CareSource Indiana (Dayton, Ohio): I anticipate significant refinements in the payer industry in the next 10 years as our memberships evolve and technology advances. I expect a greater focus on quality and outcomes with an increased prevalence of value-based arrangements with providers in lieu of fee-for-service reimbursement. I also believe there will be innovation in automation that will streamline utilization management functions to reduce turnaround times and improve member and provider experiences. As in other sectors, I expect to see growth of artificial intelligence, which has the potential to revolutionize utilization management, including medical necessity determinations, and care management endeavors. Finally, as our Medicaid members become increasingly diverse, I predict a greater emphasis on health equity to ensure the varied populations we serve receive individualized, respectful, culturally responsive healthcare.