Payers can help members and physicians with post-pandemic realities.
Health Plans

Post-pandemic: 6 ways health plans can help providers, members

June 10, 2020
Payers can help members and physicians with post-pandemic realities.
President and CEO

The evidence is in. The COVID-19 pandemic has rocked the healthcare industry.

Some hospitals have faced unprecedented challenges caring for COVID-19 patients, while much of the healthcare system has had to sit on the sidelines.

As I wrote in a blog about nine ways for physician practices to restart regular care, healthcare utilization has declined precipitously during the COVID-19 pandemic. A Commonwealth Fund study found “the number of visits to ambulatory practices declined nearly 60 percent in mid-March and has remained low through mid-April.”


Source: Ateev Mehrotra et al., “What Impact Has COVID-19 Had on Outpatient Visits?,” To the Point (blog), Commonwealth Fund, Apr. 23, 2020.


Preventive care has been particularly hard hit.

There are signs people will not be rushing back to regular care.

For starters, emergency care for heart attacks and strokes has declined by as much as 40 percent since the onset of the pandemic. Concerns about health costs have increased, with 78 percent of consumers saying they would skip at least one medical visit such as chronic illness care or a recommended lab test due to cost. Even more concerning, a survey of 5,379 adults April 17 – 23 found 60+ percent said they would wait one to six months or more to seek routine care.

Members and providers are struggling, and payers are in a position to help.

Now is the time for payers to help their hospital and physician partners determine the highest risk members and the most appropriate setting to deliver care. Increasingly, health plans are helping their provider partners by taking the lead on outreaching to and engaging these high-priority members.

Six Ways Payers Can Help Providers and Members

1.  Financial Assistance

The 60 percent decline in ambulatory care visits and the cancellation of elective procedures has hit physician practices hard. Reportedly, half of the physician practices that sought a Paycheck Protection Act loan were unsuccessful.

That’s why payers like United Health have advanced physicians and hospitals “nearly $2 billion in accelerated payments.” Some thought leaders such as Ezekial Emanuel, MD have suggested now is the time for capitation, writing:

“Health insurers should switch from paying doctors for services rendered (the fee-for-service model) to paying them a fixed fee per patient they care for (known as capitation), with adjustments for quality provided and how sick patients are.”

2.  Quality Reporting

CMS has announced quality reporting exemptions for clinicians, providers, hospitals and facilities. Other payers could follow suit.

3.  Prioritized Lists of Members with Care Gaps

Better yet, health plans can help their provider partners target and outreach to the high-risk, high-priority members. Payers can use analytics to identify members with the most care gaps connected to a chronic illness diagnosis. For example, diabetic retinopathy is an eye condition that can cause vision loss and blindness in people who have diabetes. There are no early symptoms, which is why eye exams are critical and are part of the HEDIS® quality measures for diabetics.

4.  COVID-19 Severe Impacts

Early research has suggested that people with comorbidities like diabetes, hypertension and heart disease are at higher risk for COVID-19 complications and hospitalizations. Increasingly, companies like Geneia are creating models to determine which members are at higher risk for severe impacts and hospitalization should they contract COVID-19. Combining this model output with prioritized lists of members with care gaps yields a high-impact engagement list, which can be shared with network providers. In many cases, payers have care manager resources who can take the lead reaching out to prioritized members to schedule physician and lab appointments.

5.  Telehealth Co-Pays and Cost-Sharing

During the pandemic, many health plans have encouraged the use of telehealth by waiving co-payers and cost-sharing for COVID-19 care. Others like Humana have eliminated Medicare cost-sharing for all primary care and behavioral health for the remainder of 2020.

As members continue to express fear about accessing routine and preventive care, the savviest payers are incenting the use of telehealth by educating members about the various kinds of conditions that are amenable and minimizing or eliminating member costs, while holding the provider financially harmless.

6.   Social Determinants of Health (SDoH)

Research suggests medical care accounts for only 10-20 percent of health outcomes while the other 80-90 percent are attributed to social determinants of health (SDoH) such as financial security, loneliness, affordable housing and transportation. During the pandemic, 61 percent of patients report they have been adversely impacted by SDoH, and with nearly 40 million filing unemployment since mid-March, I suspect that number may increase in the coming weeks and months.

Health plans are in a position to create and expand existing programs to address social determinants such as access to transportation and loneliness, which benefits members and the physicians who treat them. Payers are advised to make program information readily available to network practices.

Stay tuned. If, as many expect, we experience multiple waves of COVID-19, physicians and members will have additional needs, providing more opportunities for health plans to help.