For more than a decade, the U.S. healthcare industry has foretold the coming shift from a tightly controlled structure of healthcare management and delivery to a human-centric model built on powerful and accessible technology, proactive engagement, open markets, and transparency. We’ve seen some movement towards this, mostly in technological advances like telehealth mobile apps, IoT, and options for retail-based health services like cold and flu clinics. However, the prediction of flexible, consumer-driven care has not yet fully come to fruition industry-wide. But be certain, it’s coming. Because healthcare consumers demand it.
In 2017, more than 58 million people in the U.S. were enrolled in Medicare, and that number is expected to increase by 60% as the baby boomer generation ages. As a result, Medicare spending for physician and clinical services is projected to outpace spending on private health insurance. The care for this rapidly aging population will stress the financial and clinical infrastructure of today’s healthcare system, forcing it to make massive changes.
Other factors are also effecting change. The Patient Protection and Affordable Care Act (ACA) passed in 2010 requires payers to cover pre-existing health conditions, forcing them to rethink the economics of keeping members healthy. Meanwhile, individuals are seeing out-of-pocket expenses rise. As employers shift more of the costs of coverage to the individual or steer employees toward health spending accounts, healthcare consumers are questioning the status quo and seeking out cost-efficiencies as well.
All of these influences continue to push the industry toward improvements in how care is managed and delivered on a more personal level.
New business models focused on health outcomes
Studies show that the more engaged consumers are with their health, the better the health outcomes. In fact, experts have estimated that only 10-20% of an individual’s health is dictated by the care received. That means each person’s actions have a significant effect on their health and wellbeing. Payers and providers realize this and are evolving their business models with personalized health outcomes in mind, creating a shift to human-centric wellness and preventative care.
This industry shift will create more options for the healthcare consumer and more opportunities for payers, providers, and pharmaceutical/life sciences organizations to break down the barriers between organizations.
- Payers – To manage risk and retain customers, successful payers will provide more proactive, preemptive, and personalized services. Members will increasingly have more choice – Medicare patients already have the power to switch payers year to year – making effective member understanding and engagement a critical component of operations. Payers can provide a high level of service and help build loyalty by using detailed customer data and working with members to help proactively answer questions and solve issues like benefits and billing inquiries. This data-based and patient-centric approach also helps build relationships based on an understanding of each individual’s needs so that care can be better coordinated to improve health outcomes and drive improved business outcomes as well.
- Providers – Like payers, providers will also compete more and more for services. Most patients, even “in-network” patients, have options when it comes to choosing facilities for procedures and care. Successful providers will differentiate themselves through special services or costs for service. They’ll need to build relationships to partner with payers and consumers to be an active participant in the human-centric approach to care.
- Pharmaceutical / Life Sciences – To be responsive to this new type of healthcare consumer, life sciences companies will need to get digital and build relationships. Patients have options to choose generic drugs and have many organizations vying for their attention. Pharma organizations that can better personalize consumer interactions while establishing relationships through care management and delivery providers, and who can also demonstrate and convey value to the healthcare consumers using their brands, will make a place for themselves in the continuum of care.
Technology will provide the foundation for new models of data-driven, personalized health management
In the new human-driven healthcare economy, organizations will need to be able to arbitrate across wellness, care management outreach, enrollment campaigns, and other incentive programs. To do that effectively they will need to identify and understand each member or patient’s unique needs. That, in turn, requires more and better customer data and puts technology that can aggregate data from multiple sources front and center in the shift to human-centric care.
Platforms that gather, share, and communicate data and knowledge are critical to a human-centric approach to care for payers, providers, and other care resources. Such platforms are able to integrate with a variety of data sources (e.g., fitness trackers, medical records, claims info, social media, socioeconomic data, big data) to provide a more complete and personalized view of an individual and their needs and preferences, and can communicate across a variety of digital or analog channels and devices. These platforms are evolving to use artificial intelligence and predictive analytics to anticipate a patient’s propensity to engage with an organization, generate a personalized risk score, and identify current or future gaps in care. AI and analytics are also being used to generate recommendations for personalized actions, wellness programs, care team outreach, or relevant health resources.
Operational structures will also need to evolve
There are a number of challenges to infrastructure and operations that need to evolve and improve before a shift to digitally-enabled, human-centric healthcare becomes a reality throughout the industry. Health records need to be accessible and sharable. Payers, providers, and other stakeholders need to decide on systems of communication and engagement and rules that govern collaborative care. These are big changes that will require the input and actions of all healthcare ecosystem stakeholders, including the patient, but are essential in establishing a more modern framework for healthcare delivery and patient engagement that is viable for care organizations and improves the health outcomes for individuals.
Attend our Healthcare Customer Engagement Summit in Boston, October 29, 2019 to discuss issues, share ideas, and come away with actionable viewpoints. Pega is bringing together industry leaders from payers, providers, pharmacy benefits managers, and life sciences organizations in a setting to learn how to personalize engagement, automate processes, cut costs, and future-proof technology investments – and how you can do the same quickly and repeatably – with Pega’s unified platform. And while you are there, test-drive powerful new AI and automation technology that lets you engage consumers without limits and provide whole-health experiences.