By Team HGS:Donna Martin, HGS Senior Vice President, Business Development, Global Healthcare; Anand Natampalli, HGS SVP, Sales and Business Development, Healthcare; Daniel Schulte, Senior Vice President, Healthcare; and Krithika Srivats, Vice President, HGS Healthcare Practice Office
As we close the books on 2018, it’s a good time to take a peek around the corner at the trends that will drive healthcare investments and strategies in 2019.
For the past several years, HGS has surveyed the complicated healthcare landscape to determine what major stakeholders will be focused on over the next 365 days. Most of us industry stakeholders understand that healthcare costs will continue to rise, skilled staff will remain in short supply, and a newly divided federal government risks ongoing gridlock and hyper-partisanship.
However, it’s not all dark clouds on the horizon. Marketplace innovations and changes in the broader culture and society are powerful influencers on healthcare delivery. Our predictions this year reflect those ongoing transformations.
Our trends share common threads, including healthcare stakeholder efficiency and consumer-centric support options and entities . Some of these trends represent a maturation of a technology or service, while other remain nascent and brimming with possibility. How will digital technology, emerging support strategies, and consumer engagement shape 2019 for payers, providers, and patients?
Here are the major trends that we believe will drive healthcare in 2019.
TREND 1: Influence of AI Continues to Spread
Most of the attention paid to artificial intelligence (AI) in healthcare has been on the clinical side. However, we anticipate that payers and providers will find more immediate applicability of artificial intelligence on the administrative and consumer engagement sides of their organizations.
There are several reasons for this. Even in today’s digital age, most claims management and data-transaction processes are, at best, only partially automated. However, many claims management tasks are both repetitive and complex, which are ideal for intelligent automation.
AI has the potential to not only automate, but also refine and optimize many of the back-end processes that remain a chronic source of high costs, frustrated consumers, and payer-provider abrasion. On the provider side, ensuring coding accuracy and effective management of denials is essential. AI has the potential not just for automation, but demonstrated efficiencies and absolute accuracy with each claim processed. On the payer side, AI has the potential to be a reliable, efficient and cost-effective solution to mitigate the causes of improper claims payments. AI can deliver multi-dimensional analytics—aggregating data from medical records, contact centers, claims, authorizations and provider networks to capture trends (and errors) across the claims value stream. And unlike the resource-intensive and largely static nature of traditional payment integrity processes, intelligent algorithms continually quickly learn and evolve with each claim. As a result, health plans now have an opportunity to more significantly reduce unwarranted utilization.
TREND 2: Consumerism Matures
The past 10 years have been witness to an industry-wide scramble to transform the fundamental dynamics of healthcare purchasing and delivery to meet the needs and expectations of consumers.
Smartphones, texting, social media, and increased online engagement make it easy for consumers to compare prices and plans, receive recommendations, and learn from their experiences. Healthcare has spent much of this time behind the innovation curve due to its compliance driven foundation, but we are certain that healthcare consumerism and its supporting technology and services solution will continue to mature in 2019.
Health plan and provider organizations are leveraging the consumer experience as a business metric. In response, significant investments are being made to provide consumers with a unified, seamless experience across the channels and devices. Moreover, health plans and providers are beginning to seriously examine the creation of a holistic, engaged consumer journey. From benefits purchasing to care coordination to chronic self-care at home, industry stakeholders are keen to remove the roadblocks created by data silos and the business processes of disparate organizations.
The amount of data attached to every patient has grown exponentially—and all of it has to be gathered, integrated, and interpreted according to compliance guidelines and processes that can vary widely between payers and providers. Look for both payers and providers to invest more in technology and services that strengthen their analytical capabilities, because the ability to unlock those critical insights and put them to work will be a significant contributor to any organization’s ability to anticipate and customize consumers’ needs.
TREND 3: Telemedicine Goes Mainstream
Telemedicine is an increasingly preferred option for payers and providers because it increases access to care for many patients, especially those who live in rural areas, and a cheaper alternative to in-office visits.
The growth of wearables and other mobile wellness devices is expected to be a $41 billion industry by 2020, making the monitoring of patients more ubiquitous.
We predict that 2019 will signal the mainstreaming of telehealth. According to the American Hospital Association, “65 percent of U.S. hospitals connect with patients and consulting practitioners at a distance through the use of video and other technology.” The same study confirms that more than 25 percent of hospitals use telemedicine and other web-based technology, including wearables and mobile apps, to monitor patients with such chronic diseases as congestive heart failure, diabetes, heart disease and many more.
Additionally, we anticipate that clinical process outsourcing (CPO) will continue to mature, finding mainstream applications in broader ranges of care, driven in part by increased provider demand with shortages of clinical professionals. With the increasing volume of the aging population, requiring more frequent provider guidance in care, we see evidence of increasing CPO choices developing in the near future. We’ve already begun to see a reduction in readmissions, through the utilization of technological advances in remote patient monitoring and other wireless communication options, making patients more successful in recoveries from home.
TREND 4: Design Thinking Finds a Home in Healthcare
The concept has been kicking around since the mid-1960s, but design thinking has only recently emerged as an increasingly appealing approach for fueling innovation. Industries as diverse as gaming, transportation and consumer services apply design-thinking strategies to organizational goals and problem-solving. Healthcare can also benefit from design thinking, especially as the industry shifts from volume- to value-based care and both payers and providers work to better meet the evolving needs of consumers.
We predict that design thinking concepts will be more widely applied to the significant—and exceedingly complex—challenges facing the healthcare industry, supplanting process analysis approaches. This will allow healthcare organizations to tackle challenges with an approach that is multi-dimensional, iterative, human-centered, and scalable to the enterprise without compromising quality.
The incorporation of design thinking empowers healthcare organizations to break away from archaic and legacy thinking and move toward a process that keeps pace with innovations and marketplace demands.
TREND 5: SDoH Becomes an Industry Influencer
Like AI, social determinants of health (SDoH) feels more like industry buzz than industry reality. Yet more payers and providers are integrating atypical factors—demographics, social status and transportation issues—that influence a patient’s health and choices they are making.
In our interactions with payers across the US, we’ve seen they are taking steps to address SDoH in their member programs, leveraging this knowledge for improved outcomes, population health, and value-based healthcare initiatives.
While there have been some interesting use cases for social determinants, this area of healthcare remains embryonic due to a lack of metrics and compliance standards, stakeholder alignment, technology, and services.
Population health management (PHM) outreach can identify patterns of risk and avoid high-cost health events, but depends on a strategy that includes stratification to accurately identify and address high-risk populations. BPO partners are ideally positioned to support outreach with PHM intervention experience and payer-provider lifecycle and operational metrics learnings. They also bring the essential front-line automation and analytics expertise. Increasingly, health plans can align with these partners as providers of the targeted PHM outreach that bends the cost curve and also optimizes member engagement for better health outcomes.
Importantly, SDoH brings more to the table than just clinical implications. Treatment and ongoing health are happening in the home, and they must include key components to fight the health risks associated with loneliness and isolation.
TREND 6: Internet of Things—Analytics at the Point of Interaction
Today we are on the cusp of astounding advances ushered in by inserting machine learning, artificial intelligence, and the Internet of Things (IoT) into the connectivity mix. Much of the discussion surrounding the IoT pertains to simple interconnectivity: to communicating information and perhaps basic intelligence. But the future of the IoT involves intelligent decision-making from data collected at the point of interaction with the individual.
Imagine that your personal health and dietary information were augmented with information from the population in general. Information about diabetes or healthy protocols for managing weight for people like you could be mixed with your personal history to create a personalized machine-learning algorithm. This algorithm could guide you in making better decisions about your health—what you’re eating and what food you’re purchasing—all managed from your refrigerator. Such is the power of employing intelligent analytics through devices at the point of interaction.
TREND 7: Mega-Mergers and Consolidation Accelerates
The recent $70 billion merger between CVS Health and Aetna is the latest example of entities seeking more integrated care with data analytics. The desire for more market stability could cause greater consolidation among insurance carriers via mergers and acquisitions. This may also lead to more provider organizations building and managing their own health plans. In addition, venture capitalists and traditionally non-healthcare organizations (think: Amazon, JPMorgan, and Berkshire Hathaway) getting into the healthcare game will have a huge impact in 2019 and beyond.
For many provider organizations, offering patients medical services and insurance coverage may serve their integrated approach. Prior to the ACA, there was little financial incentive for providers to work as a team to contain costs. More care equaled more money. Now that notion has been turned upside down. In a value-based care world, where margins are thin and revenues are controlled by capitated contracts, everyone must work together for the common good. In many cases, employing the expertise of a strategically minded outsourcing partner will be essential to overcoming the legal, regulatory, and administrative burdens that come with consolidation.
Undoubtedly, 2019 will go down as an important turning point for healthcare, with digitization, engagement, and consumerism all bolstering the industry’s aim to meet stepped-up consumer demand.