Life in the Fast Lane: 5 Ways Health Plans Can Keep Up with the Speed of Change in Healthcare

Healthcare is moving faster than ever, and this acceleration produces increasing challenges for health plans.

Life in the Fast Lane: 5 Ways Health Plans Can Keep Up with the Speed of Change in Healthcare

As consumerism takes hold, members are placing more expectations on how healthcare works for them. Rapid technological innovations coupled with a global pandemic have hurled the industry headfirst into virtual and digital healthcare delivery. Meanwhile, big data analytics and artificial intelligence are raising new concerns about protecting members’ privacy.
Health plans that want to thrive moving forward will view these challenges as opportunities and start planning for a new future – today. Here are five areas health plans should address to keep up with the speed of change.


Consumers today expect their health plans to deliver highly personalized experiences that digital retailers like Amazon are offering. In addition, the slow but inexorable shift toward value-based care is transferring more purchasing and decision-making power into the hands of consumers. That shift requires health plans to supply their members with the information and resources they need to make more informed and healthier decisions.

Forward-thinking health plans can embrace this new set of expectations with actions that include:

  • Making information about your provider network more convenient, robust and accessible for members.
  • Providing more accurate and detailed information about pricing. Comparing prices for healthcare services should be as simple as comparing prices on a member’s favorite retail site.
  • Adding omnichannel support and communication that includes messaging, chat and email so members can control how and when they interact with your health plan.

Data is the foundation of building a more personalized experience for the consumer. “Know your customer” is the necessary first step to creating personal and meaningful communications that meet consumer expectations. Fortunately, health plans are well-positioned to build this new level of personalization because they possess an abundance of member data obtained from multiple sources.

But compiling volumes of data is not the same as knowing your members. Gaining a deep understanding of each member’s unique needs in order to personalize support requires ongoing commitment and investment in data analytics and behavioral research. To do this, health plans must:

  • Replace segmented information silos—claims, consumer management etc.—with a unified platform that can analyze all to identify trends and gaps in care in a systematic and timely manner.
  • Leverage and invest in data analytics and methods, such as risk stratification and personas, to create an integrated and comprehensive member profile.
  • Incorporate data from third-party sources, such as information about demographics, Social Determinants of Health (SDoH), consumer interactions via social media, and purchasing habits, to further refine the member profile.

For health plans, Artificial Intelligence (AI) offers an opportunity to streamline processes, improve fraud detection, and deliver a better customer experience.

Here are four ways health plans can leverage AI, according to Certifi, an insurance premium billing and payments platform.

  • Claims Processing Automation: One in 10 claims is incorrect; up to 70 percent of claims are flagged and must be reviewed. AI can help to reduce these inefficiencies by identifying and correcting errors.
  • Prior Authorization: AI can help determine which procedures require authorization and what information is needed to complete the authorization.
  • Fraud and Abuse Prevention: Preventing fraud and abuse is labor- and time-intensive. Although human resources are still required, by leveraging AI, you can review enormous amounts of data to identify fraud and abuse much faster than relying solely on employees.
  • Early Intervention: AI can transform healthcare from practicing reactive medicine, where sickness precedes care, to a more proactive approach in which data is analyzed to predict disease as well as provide more personalized early interventions.

Health plans can significantly improve population health by reaching beyond the walls of the hospital and doctor’s office to address SDoH factors in members’ homes, schools, workplaces and neighborhoods.

Here are a few steps health plans can take:

  • Include SDoH questions on health assessments to better understand each member’s non- clinical needs, social support system and physical environment.
  • Partner with community-based social service organizations that deliver healthy meals, for example, or free rides to medical appointments.
  • Leverage additional resources, such as Onlife’s SDoH Community-Based Index, the first and only mapping tool that identifies and analyzes SDoH vulnerabilities for each of the more than 84,000 census tracts in the United States.

Home health is also one of the fastest-growing healthcare sectors. In fact, up to $265 billion worth of care services for Medicare fee-for-service and Medicare Advantage beneficiaries could shift to the home by 2025. Today, almost two-thirds (62 percent) of consumers say they are willing to use telehealth. All of this, combined with regulatory changes that enable greater access and reimbursement for telehealth services, is helping to improve outcomes and affordability. Now more than ever, health plans have a new opportunity to reinvent how healthcare is delivered.

To advance efforts in this space, health plans can:

  • Expand coverage for telehealth and home health visits to make them more accessible and convenient for members.
  • Consider offering a ”virtual-first” plan in which members first meet a physician online before making a visit in person.
  • Carefully study the health benefits and economic sustainability of shifting certain care services from a hospital, specialty clinic or doctor’s office to home care.
  • Redesign benefits and reimbursement policies to support home care.
  • Partner with companies that specialize in home care as well as community organizations that provide services in the home.

These five areas of opportunity aren’t an exhaustive list of what health plans must do to win the race, but they will put organizations in a pole position for future success.

Want to learn more about how your health plan can keep up with the speed of change? Contact us today for a personal consultation.