Health Plan Investments to improve Member Experience

By Shobhit Saran, Asst. Vice President - Health Plans, CitiusTech, Aritra Roy, Healthcare Consultant, CitiusTech, Sidharth Makhijani, Healthcare Business Analyst, CitiusTech

The pandemic exacerbated persistent challenges within the global healthcare industry. It became a catalyst amid fierce competition and tight regulations for health plans, focusing their resources on price transparency; and digital health like virtual care, telehealth, remote patient monitoring and omnichannel-enabled member care. This article gives an overview of the top eight focus areas of a few CitiusTech payer customers who have shaped their investments by technological advancements, changing regulations, and emerging member preferences in a highly competitive environment.

Investment area #1: Digital Front Door

Digital Front Door (DFD) takes a modern approach to healthcare interactions that were traditionally held in-person or conducted manually, offering members a more integrated, digital and frictionless experience. A successful Digital Front Door strategy provides more ease, convenience, and accessibility to members, throughout the entire healthcare journey at every touchpoint from the very first interaction.

Cigna's Evernorth is continuing its expansion of digital offerings, starting with MDLive online provider services to its latest partnership with Meru Health, a provider of app-based digital mental health services. Eligible Cigna members can use Amazon Alexa voice controls to understand the full range of their health benefits and manage their health improvement goals to earn personalized wellness incentives while Express Scripts members can check the status of a home delivery prescription and request Alexa notifications when their prescription orders are shipped.

Highmark Health invested $750M to advance DFD, benefiting patients, members, and the community during the COVID-19 pandemic. Highmark has built a health ecosystem, called Living Health, that connects payers, providers, tech innovators, and community organizations. Highmark has long-term partnerships with Google Cloud and Verily to develop a seamless, integrated Living Health platform and digital health solutions that empower members and clinicians to be more engaged and effective in improving health.

Independent Blue Cross is providing members personalized resources and digital tools to help achieve their health goals. Significant investments to revamp the IBX member portal and mobile app. ‘Achieve Well-being’ a digital toolset powered by New Ocean Health Solutions, bridges the gap to holistic health and well-being. ‘IBX Wire,’ powered by Relay, provides ongoing, personalized communication between Independence and its members through a secure, HIPAA-compliant channel.

UnitedHealth Group has significant investments, focusing on omnichannel engagement across lines of business (LOBs), including commercial, Medicare and Medicaid. They aim to expand and reach 94% of Medicare membership , as well as cover 80M uninsured people.

Investment area #2: Whole Person Care

Research indicates that environmental, economic, and psychosocial factors can negatively impact health, quality of life, as well as put an increased burden and cost on local, state, and federal funding. Hence, while whole person care is not a new concept, it is gaining greater traction with health plans, providers, and investors. As a multidimensional approach for coordinating various healthcare services, behavioral health, or other personal and social services, payers are investing in whole person care to achieve improved health outcomes, eliminate duplicate efforts, and deploy resources in a cost- and time-effective manner.

Cigna has a comprehensive pharmacy, medical, and value-based care (VBC) solution like Health Connect 360 with integrated behavioral, genomics, and social determinants of health (SDoH) to support whole person health needs.

Evernorth is focused on integrating its subsidiaries -- Express Scripts, eviCore, Accredo, and MDLive -- to deliver whole person care to their members. Evernorth’s total addressable market for care services is currently $370B, having a growth potential of $600B to $800B by 2026.

Cigna has launched whole person health plans that include medical, pharmacy, and mental health coverage. Members will have access to 24/7 live customer service supporting medical and behavioral needs.

Cambia plans to expand, diversify, and train their behavioral health workforce to reduce provider shortages across Idaho, Oregon, Utah, and Washington. Cambia Health Foundation has funded over $80M in grants to advance whole person-focused healthcare. Cambia has invested in a palliative care workforce through the Sojourns Scholar Leadership Program, expanding access to whole person health for individual living with life-threatening, serious illnesses.

UnitedHealth Group (UHG) integrates medical and behavioral benefits to help achieve whole person health. UHG uses a range of innovative offerings to provide employees with access to quality care,  including digital and web resources like and and mobile apps like Talkspace, AbleTo, and Sanvele. Their offerings also include advocacy support with access to behavioral health clinicians.

Investment area #3: Care Architecture

As part of their care management strategy, health plans are engaging specific members and their care ecosystems to enable high-value decisions and increase ROI.

Cigna has strengthened its comprehensive gaps in care solution, ‘Well Informed Gaps in Care’, by offering RationalMed. It is a way to help improve the health and safety of members and achieve greater affordability. RationalMed will work in addition to Well Informed; estimated to yield an additional $0.63 PMPM in pharmacy savings for Administration Service Organization (ASO) clients.

Cambia’s strategy now focuses on the Regence Care One program to improve personalized care experience and enable faster gap closure. They are committing around $1M+ in their 2022 roadmap to  improve personalized engagement capabilities and campaigns.

UnitedHealth Group is focusing on customizing member outreach and engagement for care management and care gaps closure. Significant investment have been made in a project to study member behavior  through their campaign management site, as well as creating customized offerings.

Investment area #4: Consumer Analytics

Health plans aim to benchmark themselves across metrics for a diverse population and design a personalized care journey that improves member outcomes.

Cambia is working on a comprehensive data strategy to create a single source of truth, enabling consumer analytics and personalized outreach. Investments are being made in data solutions, like Abacus Insights, for data strategy and integration of disparate datasets.

Investment area #5: Online Bill Pay

Health plans are also investing in adopting digital payment models and payment integrity algorithms to create a seamless payment experience with a significant reduction in fraud, waste, and abuse (FWA).

UnitedHealth Group is integrating an end-to-end health banking and payments experience using Optum Financial B2B payment solution for claims. Focus areas are Payment Integrity and AI (Artificial Intelligence) enabled value-based analytics. Aiming to realize $30B annual savings through payment integrity.

Investment area #6: Compliance Mandates and Modernized Engagement

Health plans now need to be compliant with regulations, such as Interoperability and Patient access and price transparency with the goal of empowering members and improving quality of care.

Most payers (e.g. Highmark, Aetna, Cigna, United Healthcare, CareFirst, IBC, Cambia, and BCBS plans in states like MA, IL, NC, MN,) have built self-service cost estimation tools for members to compare prices of different services as part of the Centers for Medicare and Medicaid Services (CMS) price transparency mandate. Also, payers are making significant investments in analytics leveraging publicly-available pricing data to achieve competitive pricing and lowering healthcare costs.

Investment area #7: Virtual Care

Health plans are currently partnering with telehealth and home care providers to enhance accessibility, affordability, and lower unnecessary in-person services.

Cigna is investing in ‘Site of Care Optimization’ via MDLive and Evernorth care services. They launched a remote patient monitoring (RPM) program with MDLive to track and report biometrics, like blood pressure and glucose levels, to their virtual primary care providers who can then review the data with them during their visits.

UnitedHealth Group has launched a virtual-first health plan called "Navigate Now" with 350K members. Investments are focused on home healthcare, value-based care, lowering cost, and care delivery integrations. Recent investment in LHC Group will expand in-home healthcare and health benefits management.

As part of its long-term strategy, Cambia has made significant investments in home health firms,  including Dispatch Health and Tytocare, as well as investments of $11M and $33M in Tytocare and Dispatch Health, respectively.

Independent Blue Cross (IBC) has made investments in local health systems focused on telehealth, home-based care and others along with investments through clinical care innovation grants to Penn Medicine, Jefferson Health, Temple Health, and Trinity Mid-Atlantic.

Investment area #8: Prescription Digital Therapies and Digital Health Formulary

The payer market is witnessing significant growth in the application of formulary and digital therapeutics (DTx). Combining technology and evidenced-based medicine, DTx products offer members access to therapies that address a wide range of conditions, enabling payers to reduce cost of care and optimize member engagement.

Cigna's Express Scripts has already set up a national preferred formulary focused on improving patient access to digital health solutions.

Evernorth has built significant supply chain expertise through SafeGuard Rx, saving $32B annually.

Cigna is seeking to capitalize on emerging growth opportunities particularly in pharmacological innovations like biosimilars. Eyeing a $100B market with a $30B opportunity for Evernorth, they are creating strategic partnerships with Prime Therapeutics (retail pharmacy network and pharmaceutical manufacturer contracts) and Kaiser Permanente (preferred external pharmacy partner).

UnitedHealth Group plans to strengthen its direct-to-consumer offerings, capturing a share of the growing life sciences market. Seamlessly integrating medical, pharmacy, behavioral and community health capabilities, OptumRx’s PreCheck MyScript delivers real-time, personalized prescription information and makes suggestions for other clinically-appropriate, lower-cost alternatives. It has the potential to streamline the approval process for drugs. Investments made in Genoa Healthcare will add 400+ pharmacies to its pharmacy benefit management (PBM) system.

CitiusTech payer clients are leading the way with investments in technology and support.

Throughout 2022 and in the years to come, dynamic factors will motivate payers to continuously evaluate and develop fundamental value propositions. We’re helping our customers deal with compliance mandates, alternative care delivery models, increased use of predictive analytics to support wellbeing and disease prevention to create top notch member experiences. Together, we’re accelerating the payer industry’s digital transformation.

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