Washington, DC has been a hotbed of healthcare-related activity for the past few months. After several advancements and setbacks, the administration's pursuit to repeal and replace the Affordable Care Act (Obamacare) ultimately did not move forward. Now, many are left scratching their heads at the thought of what is currently happening and what to expect next.
Although we can't predict the future, we can help you get up to speed and brace for what is likely to happen next. Here are some important things to consider with recommended IT actions for healthcare payers and providers.
Look to health plans and individual states to act
America's Health Insurance Plans (AHIP), the largest health insurance lobby in the country, warned the Senate against repealing the individual mandate unless some other legislation that pressures citizens to maintain coverage is included. The Blue Cross Blue Shield Association had similar views. Why? Possible changes to the individual mandate threaten business for insurers across the country.
The effects of legislative change around this mandate are already unfolding: Molina Healthcare, Inc. has said it would stop selling Obamacare plans in select states; Anthem, Inc. has pared back offerings or even exited several states. Negotiations between local governments and insurers in key states where the exchanges are under stress are anticipated.
- IT Recommendations: In order for healthcare payers to profit under the ACA, organizations must invest in analytics and core administration efficiency to effectively target micro-markets. Automating core administrative system processes speeds overall operations, leading to more satisfied members. Healthcare providers must continue to evolve their care delivery economics in a climate of tighter reimbursements and narrower networks.
There is opportunity for smaller, nimbler local plans. Appian, The Digital Transformation Platformô, can help with these challenges.
Medicare Open Enrollment is coming soon
Medicare is America's biggest government insurance program. Open enrollment for fiscal year 2018 is quickly approaching, running from October 15 to December 7.
By 2018, Medicare will provide health insurance to 60 million individuals who are age 65 or older, disabled, or have end-stage renal disease. In fiscal year 2018, the Office of the US Actuary estimated that gross current law spending on Medicare benefits will total $704.6 billion. Of that, Part A (hospitalization) claims $202.8 billion and Part B (outpatient supplemental) will consume $201.9 billion. Part B coverage is voluntary, and about 91% of all Medicare beneficiaries are enrolled in Part B. The remainder is spent in Part C (Medicare Advantage) and Part D (prescription drug coverage.) This is a lot of money and a lot of covered lives.
- IT Recommendations: Both providers and payers will need to find new and innovative business models to continue to profit. Appian can help providers, who are currently dealing with MACRA reimbursement provisions, with a unified platform approach that gives visibility into payments. Further, providers can deliver better patient experiences using Appian's process automation capabilities to accelerate key decisions with end-to-end care delivery. On the payer side, new ways to expand successful Medicare programs through organic enrollment growth or acquisition will become necessary. Streamlining the Medicare enrollment process with process management and automation will ultimately lower the cost to service this population.
Despite all of the uncertainty, one thing is guaranteed: a flexible application development platform that allows you to be agile and responsive to whatever happens next is critically necessary.
Appian has a low-code approach to application development that allows organizations to build powerful apps up to 10 times faster than traditional development, so you can react to changing legislation in a nimbler way. Plus, process automation, including a new Appian RPA with Blue Prism robotic process automation offering, cuts operational costs while spurring efficiency and the ability to develop more innovative business models. This gives competitive differentiation and confidence to organizations in a market that is consumed by uncertainty.
Learn more about our platform and how it can be used to quickly and securely help healthcare organizations by visiting our healthcare resource site, and send me an email at Cate.McConnell@appian.com to discuss how Appian transforms healthcare organizations facing digital (and political) disruption.
Cate McConnell
Practice Leader, Healthcare Payers
