Payer Experiences and Challenges: Now and Moving Forward

Payers would appear to be in the catbird seat in the American healthcare system. But that doesn’t mean this vital cog isn’t also buffeted by similar forces and challenges as patients and clinicians, including in digital health, artificial intelligence and machine learning, and financial health, according to HIMSS Global Health Equity Network member Abner Mason.

“Healthcare isn’t getting simpler or easier or less costly—only more complex and more costly,” said Mason, founder and CEO of ConsejoSano, a patient engagement and care navigation firm that partners with health plans and provider groups serving Medicaid and Medicare Advantage patient populations.

“Given that, it’s not surprising that payers are going to have to be at the forefront of figuring things out,” Mason said. “Because they control the money in healthcare—which is such a huge proportion of the economy—payers, I’d argue, are only going to play a more important role going forward.”

Mason, who draws on personal and professional experiences to drive healthcare and policy leaders toward equitable solutions, shared perspectives pertaining to these three key realms, along with his take on necessary future steps as the pandemic eases.

Digital Health

One unquestionable upshot of the massive increase in virtual healthcare encounters during the COVID-19 crisis has been cost savings for these organizations, Mason said. And while they initially had to scramble to change regulations surrounding telehealth reimbursement, nearly all stakeholders have reaped benefits.

“A lot of studies show virtual visits and remote monitoring are cheaper than going to the doctor, and that’s a good thing,” Mason said. “There’s no question it’s a money-saver for payers.”

More importantly, telehealth was a solution that allowed people to get access to care when they otherwise wouldn’t have.

“Overall, the pandemic forced us to do something we should have done a long time ago—to make virtual visits more common and available to everyone,” Mason said.

This drive toward digital health, however, also exposed the need to better understand who their members are and their needs. Medicaid in the U.S. covers people hailing from numerous cultures and speaking a variety of languages. The uptake of digital health tools may improve if messaging is customized for each population.

“It makes it hard for plans to introduce new digital health tools when engagement is a challenge,” Mason said.

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AI and Machine Learning

One pivotal way they can better understand their member base is with greater use of AI and machine learning tools, Mason said. With the movement toward value-based care, this technology stands to trim costs not only by supporting clinical decision-making, but also by promoting administrative efficiencies and streamlining medication adherence.

“Value-based care is better at predicting how people behave, and that’s where AI and machine learning can be powerful tools,” Mason said. “They can also help payers craft contracts that make sense for their organization, but also for the provider partners.”

In the years ahead, organizations can optimize their benefits from AI and machine learning by using the tools to “double down on value-based payment arrangements,” Mason added, cautioning that implicit bias “infecting” certain aspects of AI first needs attention.

“Once we really start to make that shift, everyone is going to be desperate to predict how people will engage and behave,” he said, “and I think that’s how AI will be powerful going forward.”

Financial Health

While it may seem counterintuitive, the lack of transparency surrounding healthcare costs is a pressing issue for some payers, just as it is for patients and clinicians. Here’s why: This opacity can prevent patients from understanding forces influencing policy.

“So many Americans have insurance coverage through their employer, they don’t know what anything costs in healthcare,” Mason said. “When you don't know how much anything actually costs, it's difficult to understand the perspective of the person paying the bills. Price transparency would help healthcare consumers actually be able to make judgments and act like consumers.”

But a tug-of-war still exists between those who advocate for up-front pricing information and others who “lean toward the status quo” because they’re wary of change. In California, for example, legislative efforts to create healthcare price lists has met with opposition from all industry stakeholders except consumers.

Meanwhile, their financial health stands to benefit from the Centers for Medicare & Medicaid Services’ increasing adoption of MVPs, or merit-based value pathways, disease- or specialty-specific measures that enhance care and cut costs. Clinicians likely face more challenges than payers adapting to MVPs, Mason says, but “overall it’s a positive thing.”

“An important relationship in healthcare is between the payers and providers—the payer and their network—and they have to work together to deliver care to the patient. That relationship isn’t always easy,” Mason said. “So having better ways for payers to understand who the best-performing doctors are and helping them shape their networks is an opportunity for payers.”