Right now, you may not be reading about much else: the coronavirus—COVID-19—is currently taking an enormous toll on individuals, families and governments. As Americans adjust to the reality of what will be required over the coming not just days but months, Geneia is deeply focused on the rapidly changing needs of our customers and our industry. Given this, today we’ll focus on what we see as the most acute challenges that health plans and payers face around COVID-19, with some early thoughts around how analytic insights can help.
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 will play 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 the Trump administration has expanded Medicare coverage, private insurers like UnitedHealth 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, there’s still a lack of clarity around key coverage issues, such as out-of-network services. Given hospital bed shortages, health plans will likely face a range of questions around how to serve members who need to go to facilities outside of their covered network area very soon.
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
Data Science Insights
Second, 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.
Social Determinants of Health
We’ve talked about the importance of social determinants of health extensively, but the current situation underlines the necessity of understanding member access issues. For instance, as cities face the prospect of lockdowns 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 even ongoing income will be a problem for families as schools and businesses temporarily close their doors.
Prospective and Pescriptive Provider and Hospital-related Analytics
Physician availability and performance will be 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 to figure out where to go for testing, symptom checks and possibly longer-term monitoring while they recover, payers will play a key road 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).
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 we also 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 other Geneia customers; for instance, we know that rural hospitals are particularly hard hit in terms of hospital beds and resources, and we hope to offer up more thoughts on how we can all work together to support members and patients.