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We've seen much digital evolution in healthcare, one could even say revolution, within the last few years. The pandemic forced us to be innovative with technologies that have been available for some time, utilizing them in ways promoted by "outside the box" thinking. These new perspectives gave way to rescripting care delivery models, vaccination development, acute care operations, clinical treatments, clinical trials and many other healthcare and life science pathways.

Technology alone was not the only means of this transformation. Focus on data maturity practices promoting key clinical and administrative insights, solutions to support staff to work at the height of their scope of practice, policies (i.e., Public Health Emergency) and innovative processes were critical to this welcomed experience.  

A significant sector of the healthcare ecosystem focusing on transformation is the payor or insurer space. We see people wanting to engage more in their care and expect these journeys to reflect that of other industries such as retail, service and hospitality. They are looking for frictionless, affordable, accessible and comprehensible experiences when they need care. This influence comes partly from non-traditional players, such as big tech, big box retail and start-ups. Other inspirations come from focusing on lifestyle changes and prevention vs. episodic transactional sick care, as evidenced by shifting reimbursement models. Payors at the forefront are taking stock and making strategic investments to ensure they are in a position to provide the experiences their members are expecting. Here are some of the transformations these traditional payors are heading up.

Virtual care

Providing a seamless platform where IoT/wearable devices are utilized by members who may need chronic care management or other hospital-at-home needs is top of mind. We see more and more payors implementing technology, data, people and process initiatives to monitor vulnerable at-risk populations. For example, some large payors use remote patient monitoring (RPM) for expecting mothers with high-risk pregnancies to be proactive if the mom or baby needs intervention. Additionally, they are partnering with digital health companies to monitor diabetic patients' physiological data, medication compliance, diet and exercise while providing clinical guidance to stay within their ideal thresholds. There are many clinical use cases where young digital health technology companies offer clear value to traditional payors members.

Digital-first insurance

The US spends a great deal on healthcare, approximately $3.6T. However, the amount we spend doesn't always equate to better outcomes, and it turns out a great deal of waste is part of this amount, about 25 percent to be exact ($760B to $935B). There are a many reasons for this waste; failure of care deliver ($102B-$166B), failure of care coordination ($27B-$78B), overtreatment or low-value care ($76B-$101B), pricing failure ($231B-$241B), fraud & abuse ($59B-$84B), and administrative cost ($266B). Payors implementing digital tools focused on some of these areas will be able to eliminate some of the friction and wastefulness their members experience. Offering human-centered digital touch points that bring proactive clinical and administrative prompting supported by the efficiencies of advanced analytics and automation can significantly impact administrative cost, which is the low-hanging fruit. Payors offering these digital tools that support their services bring their members a more personalized unique painless proficiency. Several incumbent payors are moving in this direction; however, the non-traditional digital health start-up is leading this digital-first experience because they control their tech stack from beginning to end.

Healthcare journey wayfinding

Payors know that their members yearn to have a smooth, uncomplicated journey when they travel down the healthcare highway. It should be automated, guiding the member along so that their experience is seamless — a digital healthcare road map. I like to think it should be as easy as using Waze. You indicate where you want to go and when you want to get there. The technology uses data and advanced analytics to avoid traffic, construction and accidents and even warns you of speed traps and traffic light cameras. You know your speed, the posted speed limit and the estimated arrival time. It helps you avoid the unknowns. 

Unfortunately, navigating the twisty, dark, potholed healthcare road is difficult for ninety percent of our population. Payors taking a digital healthcare marketplace approach that can be easily understood and highly utilized by its members to do digital triage, automatically connect you to the right level of care in your network, communicate the estimated cost of the encounter prior to your visit, offering a virtual or in-person appointment depending on the reason for visit, allowing you to choose an appointment date and time that is convenient, wayfinding you to the place of care if you're seeing a clinician in person, providing easy to understand education and support personalized for your care, and simply pay one bill are making headway.

These are all critical "care-abouts" that payors strategically plan and drive to execute. However, many large payors realize to make this an authentic experience for its members; they first need to take stock of their current IT infrastructure, migrate data silos to an appropriate environment, explore potential cloud strategies, ensure a strong cybersecurity posture and consider additional foundations core to support their visions. Furthermore, newer digital health companies built their business around their technology stacks, making it easier to pivot and meet member expectations. This adds competition to the equation for incumbent payors.

With all baby boomers joining the 65 or over club in eight years, pushing this to 21% of our US population (71M people), we will see more Medicare and Medicare Advantage members. What's to stop employers and CMS from contracting directly with these digital health players? Nothing! During this last enrollment period, we have seen digital first start-up payors erase Medicare Advantage market share from traditional payors. The signs are clear, and the time to pivot is at hand.

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