Posted: 23 Jul. 2020 10 min. read

In a post-pandemic world, health plans should focus on care and utilization management

By Mike Van Den Eynde, managing director, and Ebben Smith, M.D., managing director, Deloitte Consulting LLP

The COVID-19 pandemic has had a painful impact on the health care sector and on the overall economy. However, the accelerated use of technology (e.g., telemedicine and digital-care management) has been a welcomed byproduct for health plans and their members. As the country adjusts to living with an ongoing pandemic, health plans have an opportunity to make smart investments in modernized, agile, and effective medical-management programs.

Over the past several months, health plans have relied on care management (CM) and utilization management (UM) to support members at each stage of the pandemic. Some health plans have been reaching out to their sickest members—as well as to members who might be at higher risk for a COVID-19 infection—with resources and expanded access to telehealth. In the past, CM programs have relied primarily on traditional models (e.g., nurses making phone calls to members) and UM processes have been largely inefficient.

In an unprecedented demonstration of near-industrywide commitment, many health plans have modified their UM and benefit rules to make access to COVID-19 testing and treatment less burdensome (e.g., waiving prior authorization and copayments). These measures typically include some operational challenges, including manual workarounds that make it possible for health-plan employees to quickly respond to the needs of members.

At their core, health plans want to help members get the care they need and ensure the care is affordable. In the context of recovering from COVID-19, however, there are some unique considerations. 

Identify members who might benefit from outreach

Health plans will likely need to rely on CM and UM to effectively manage some repercussions of the COVID-19 crisis. For example, there could be a significant spike in preventable illnesses due to members who were not able to meet with their doctor for routine check-ups. The pandemic might also keep some members from effectively managing a chronic condition. During the 10 weeks after the US declared COVID-19 a national emergency, there was a noticeable drop in the number of Americans who sought care at emergency rooms, even for urgent issues like heart attacks, strokes, and hyperglycemic crises (a life-threatening complication of diabetes), according to a report from the US Centers for Disease Control and Prevention (CDC). Compared to pre-pandemic times, about 20% fewer people visited emergency rooms for heart attack and stroke care during those 10 weeks, and 10% fewer patients made visits related to diabetes care, according to the report. Patients who put off essential care might need additional support to manage new health conditions or conditions that have been exacerbated.1

Some members might also seek care from out-of-network providers if in-network facilities are backlogged with deferred procedures. Health plans also could see increased mental and behavioral health issues among members due to the mental stress of social isolation or job loss. Health plans should identify members who could benefit from outreach before quality of care declines and subsequent cost of care increases.

Four strategies to transform care-management programs

Health plans that are able to transform their CM and UM functions could be better positioned to meet the changing needs of their members. Here are four strategies to consider:  

1.    Upgrade analytics: The ability to collect and aggregate data about members could help health plans more effectively identify and stratify members who might benefit from outreach. With a seismic shift in the socio-economic situation of much of the population, legacy data sources and algorithms could fall short of what CM needs to be most effective. Enhanced interoperability, multi-layered risk models, personalized action plans, and the ability to deliver next-best actions are essential components of a high-functioning program.

2.    Redesign CM to align with emerging priorities: Near-term redesign should rebalance CM programs so that they can adapt to shifting enrollment and the changing needs of members (e.g., getting care for chronically ill members who deferred care). Realigning CM should be a priority, given that some COVID-19 survivors could suffer lasting physical and psychological effects from the disease. Care models should also integrate behavioral health and health-care drivers. Over the long-term, CM models should emphasize digital engagement. This could help health plans connect with more members at a lower cost. Reconfiguring and reskilling staff to effectively integrate with technology requires a thoughtful approach that manages administrative costs while allowing staff to work at the top of their licenses.

3.    Automate utilization-management programs: Automation can help health plans minimize manual intervention and reduce friction for members and providers. The cost of manually processed authorizations can be exorbitant. Health plans that modernize their systems and processes can reduce or eliminate manual work. This can help make UM staff more efficient by ensuring they have the most relevant information and are able to streamline what, when, and how authorizations are required. This may require upgrades or entirely new platforms with capabilities allowing for user-friendly configuration to meet the evolving needs of health plans.

4.   Integrate virtual health across plan assets: Telemedicine has played an important role in the pandemic by creating access for members unable or unwilling to seek in person care. By integrating telemedicine into a broader virtual-health strategy, health plans can create a more seamless experience for members. Steps to consider include enhancing the network to fill any gaps, setting a pricing strategy to optimize use, improve technology tools to increase adoption, and integrating with other digital offerings (e.g., AI-based triage) to make virtual health an extension of CM programs as well as a digital front door to health care.

By taking steps now to realign CM and UM as critical strategic assets, health plans could gain competitive advantages by designing programs and leveraging technology to improve the member experience, ensure access (at a time when members may be reluctant or unsure how to get necessary care), and future-proof against unpredictable shifts in the delivery system.

Endnotes

1.        Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020, CDC, June 12, 2020

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