4 Market Trends Impacting Healthcare Plans | AHIP 2024

Four trends are converging in healthcare that are creating both challenges and opportunities for plans, agreed panelists during a session at the annual AHIP meeting in Las Vegas.

Sam Yamoah

But addressing those challenges — increased health demand, decreased physician workforce, technology advancements and more government involvement in healthcare — will require health plans to keep their mission at the forefront, Sam Yamoah, chief strategy and innovation officer, Cambia Health Solutions, an umbrella organization for Blue Cross Blue Shield health plans, said during the session. The Blue health plans under the Cambia umbrella are located in Oregon, Washington, Idaho and Utah.

“Why do we as an insurance industry exist,” Yamoah asks. “One is to ensure that the product we provide is affordable. And when members need it, they can get access to it. We are here to improve healthcare. That is our core mission.”

An older population, more complex diseases, new drugs with higher prices and new information technologies have created a healthcare delivery system that is costly and often fragmented.

The goal as insurers is to provide better experiences and lowered costs, Yamoah said. “There are solutions that we need to figure out how to integrate that deliver specific results,” Yamoah said. “My colleagues published a paper three years ago now talking about integrative care leads to the lower hospitalization, better experience and lower costs.”

Technologies such as virtual care may help to solve the problem of physician supply, and artificial intelligence has been proposed as as a way to automate additional processes in healthcare delivery, he suggested.

Integrating the various technologies used by providers and patients, however, has to be a priority, he said. “If someone has multiple chronic conditions, they see multiple providers with different apps. And then there is the insurance app. Is this the experience that you want for your family? Probably not.

“If we’re not careful, we could create a fragmented solution,” Yamoah continued. “If we don't do our jobs, others will compensate and deliver value better.”

Sonny Goyal

Integrated solutions are possible, Sonny Goyal, senior vice president, Diversified Business Group at Blue Cross and Blue Shield of North Carolina, said during the session.

Back office processes that are manual can be automated, and AI can be leveraged to improve analytics capabilities, he said. For example, instead of having nurse managers call high-risk patients, AI can help to reverse that process and identify the people who need more support. “We can come up with analytics that can drive more impact to our businesses.”

Automating front office processes such as call centers provide more of a challenge because companies still need to have a personal engagement with the customer, Goyal said.

“We need to make sure that we put in the right governance structure to make sure that we are not allowing the machine to take over,” he said. “We have to make sure that a human is involved in some way.”

Yamoah said during the session that if health plans don’t make the effort to delivery high-quality care at reasonable costs, federal and state governments will and have stepped in. “In an efficient market, the market should solve a problem. But when the market doesn't solve the problem, others will intervene. The challenging thing is that interventions may not look at the entire system.

“Whether it’s your Medicaid MCO or Medicare Advantage, or an exchange plan, if it doesn't appear that you’re delivering value the government will step in,” he continued.