Digital transformations have spread across the payor industry in recent years as organizations attempt to adapt to changes to regulations, industry care models, consumer expectations, or even working methods.
Yet digital technology is more than just an obligation. The right implementation increasingly offers profitable and intriguing use cases. What’s important to emphasize is that there are plenty of persuasive applications that can transform the capabilities, cost-effectiveness, and care metrics for organizations throughout the healthcare payor space – especially with current market maturity and a wider stakeholder acceptance.
Based on our experience and observations, these are some of the trends for digital transformations in healthcare that will offer the most substantial return on investment.
Virtual-First Models
During the pandemic, the industry switched operations, as well as member appointments whenever possible, away from in-person to virtual interactions and modalities. The response of the Office for Civil Rights at the Department of Health and Human Services, declaring they would be practicing enforcement discretion and forgoing any HIPAA violations occurring during good faith provisions during a global emergency, opened the door to wider telehealth implementation.
More than simply earning government approval, the model has been a success with certain healthcare specialties as well as consumers. McKinsey shows an uptick in telehealth utilization for psychiatry (50% of appts.), substance use disorder treatment (30% of appts.), endocrinology (17% of appts.), and rheumatology (17% of appts.). Moreover, the same report showed 40% to 60% of consumers are interested in “broader virtual health solutions” or even lower-cost virtual first options.
After having seen the benefits first-hand, a number of major payors are investing in these virtual-first models. Cigna, UnitedHealthcare, Blue Care affiliates, and other organizations are exploring everything from default virtual interactions for new patient intake and follow-up visits to seamless online appointment scheduling and $0 copays on virtual visits. For organizations trying to avoid refunding unspent premiums due to the medical loss ratio (MLR) delineated under the ACA, this practice can be a way to reinvest in treatment for policyholders that retains a portion of member remittance.
There are other potential use cases being explored such as increasing the occurrence of various stages of longitudinal care, some of which can help when improving HEDIS scores to attract more members. There is even an opportunity for remote patient monitoring and self-diagnostics which can reduce costs as you help members transition from inpatient to outpatient treatment.
Conversational AI
Healthcare consumers want answers to their questions, whether urgent or low stakes, with minimal effort on their part and a rapid response from your agents. The proliferation of digital channels has helped to address some of those concerns as well as consumer communication preferences. However, one opportunity for digital transformations in healthcare to enhance the ability to address member pain points and remove obstacles from their path is finally ready for prime time: conversational AI.
Artificial intelligence in healthcare has long been a promising tool. The concept of conversational AI combines technical capabilities like machine learning, natural language processing (NLP), and voice tech into a solution that addresses consumers’ questions with accuracy and an understanding of linguistic nuance. This can provide payors with an opportunity to enhance CSAT scores while also reducing operational costs, especially with the typical customer interaction costing $5 to $15 per interaction.
In a pilot program for Humana, the Fortune 500 insurer achieved cost-efficiency and effectiveness of addressing incoming member and prospective customer questions. Most of the over one million calls they received managed to bypass their interactive voice response (IVR) system, but 60% of those could have been addressed by precise answers delivered by a tool that understood the questions. By implementing conversational AI, Humana was able to double their response rates for one-third of the cost – and free up agents for more complex calls.
2022 might be the perfect year for the widespread adoption of conversational AI for a variety of reasons. One has to do with the maturity of the technology now that a growing number of algorithms can achieve NLP as well as natural language understanding (NLU). Moreover, the approaching enforcement of the Transparency in Coverage rule on July 1, 2022, might accelerate the transition. One of the key provisions is that machine-readable files for in-network rates and allowed amounts are made available for easy consumer review. If more payors are investing in conversational AI technology, the required sharing and disclosure of pricing information will be less arduous for agents – and a snap for members and prospects.
Secure Access Service Edge
Is there a risk that for every one step forward in digital transformation, you take two steps back? Possibly, if payor organizations fail to take their cybersecurity as seriously as they do the rest of their modernization strategies. The biggest data breaches in 2021 actually resulted in the exposure of 22.6 million patients, which will have the fallout of eroding member trust and well as eliciting thousands or even millions of dollars in HIPAA penalty fines.
One trend that will be vital to overall digital transformations in healthcare organizations is the acceptance and implementation of Secure Access Service Edge (SASE). This security framework is designed to consolidate the plethora of security and network technology into a unified cloud-based platform which mitigates the side effects of digital business operations and an increasingly mobile workforce. The goal is to provide heightened security protocols as more business users and devices leave the cloister of the enterprise firewall.
Built upon the zero trust security framework, SASE requires every device or user – regardless of the frequency with which they access critical applications, networks, or data – to authenticate and verify their identity upon each access session. No unconditional access is ever granted. Industry experts forecast that by 2024, 40% of enterprises will have defined strategies to adopt SASE, thanks in part to the pandemic and increasingly virtual operations. Payors that adopt it sooner than later will be able to maintain higher security standards and hold onto more of their hard-won profits.
Identifying IT Solutions with the Greatest ROI
As we’ve all learned over the past few years, the prevailing winds can shift at a moment’s notice. Digital transformation trends that might seem inconsequential now might be your differentiator in a year’s time. Keeping a shrewd eye on the movements of the market, maturation of IT solutions, and the use cases spreading across the industry is instrumental to staying competitive from a financial and customer service standpoint.
Often, IT leaders within healthcare payor organizations will need to supplement their own knowledge and finite resources with those of IT and data management solution partners. More than just jumping on the bandwagon and seeing where it will take you, an effective partner can help you dissect the payoff and determine where to put your focus in 2022 and the future.
Ready to harness digital transformations in healthcare for your advantage? Learn more about the different ways to enhance your digital capabilities by checking out our healthcare payor insights.
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