Payers are responding to the COVID-19 crisis in a variety of ways. With the unprecedented scale of this event, we've noticed a rapid shift towards even deeper adoption of digital tools and technologies. For instance, telehealth is playing an important role in supporting patients by allowing hard-hit states to access physician services from outside state borders; telehealth will also help limit social contact. While CMS has expanded Medicare coverage, private insurers are also offering members more telehealth benefits to combat the virus.
Questions about networks also abound. Although health insurers will generally waive cost sharing as it relates to COVID-19 testing and many are doing the same for in-patient hospital admissions, there's still some absence of clarity around key coverage issues, such as out-of-network services. Given hospital bed shortages in coronavirus hotspots, health plans will continue to face a range of questions around how to serve members who need to go to facilities outside of their covered network area.
This brings us to the question of how technology vendors can help payers with the many unknowns in this quickly-developing situation. Here are a few early thoughts on how analytics might help solve some of the massive payer challenges brought on by COVID-19:
- First, analytics will drive vulnerability or likelihood of complication scores, so that payers know what percentage of their population is likely to suffer severe outcomes from COVID-19. Insights around chronic conditions, long offered by population health vendors, will have more impact now than ever before: according to the Cleveland Clinic, we know that COVID-19 severity is worsened for those that:
- Are over age 65.
- Have cancer.
- Have hypertension.
- Have lung disease.
- Have diabetes.
- Have heart disease.
- Have another condition that compromises the immune system.
- Are taking medications that suppress the immune system. As cases grow, data scientists will likely help provide deeper insight into how exactly certain chronic conditions influence COVID-19 outcomes, through more accurate likelihood of complication models and clinical decision support that helps in treating individuals with COVID-19 and underlying conditions.
- The current situation underlines the importance of social determinants of health and the necessity of understanding member access issues. For instance, as state stay-at-home orders continue and worries over public transportation grow, some with chronic, serious conditions may struggle to seek the right level of ongoing care or pick up medications. Lack of resources such as school meals or ongoing income have become a problem for families as schools and businesses have closed their doors. Other members have — or will face — unemployment and the loss of employer-sponsored health insurance.
- Prospective and prescriptive provider and hospital-related analytics: Physician availability and performance are crucial to mitigating this crisis. We know that physician resources and hospital beds are strained in the U.S. As more and more patients access health plan and state-provided-resources, payers will play a key role in collaborating with doctors and government to determine how quality care can be delivered to the highest number of people. Payers have long been pushing for appropriate levels of care; with COVID-19, we know the first step is to call your provider, not rush to an emergency room (based, of course, on severity of symptoms).
- Utilization: Expanded utilization reporting will help health plans get a better handle on member needs as the pandemic continues, allowing them to adjust benefits and coverage accordingly. As discussed above, we expect to see coverage and varied new options for digital services—telemedicine, mobile counseling—expand.
- As such, deeper, more unified analytics around how members are using these resources will be necessary for payer success. Additionally, as mentioned above, payers will need to undertake more extensive out-of-network reporting while seriously considering if utilization outside of existing networks signals a need to expand or change their approach to network management long term.
Of course, given the uniqueness of this current moment, the above list is just a start to describing the challenges our health system will face, and how technology will assist. Over the coming weeks we'll be considering the impact of the current emergency on health plans, hospitals and physician practices, and hope to offer up more thoughts on how we can all work together to support members and patients.