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Navigating Change: How Payers Can Stay Agile in a Shifting Landscape · Becker’s Payer Issues Podcast

• 0:00
  Hello, everyone. This is Jacob Emerson with the
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  Becker's Healthcare Podcast. Thanks so much for tuning
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  in today where we're thrilled to be joined
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  by Angie Adams, who is the vice president
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  of product management at I three Healthcare Solutions.
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  Angie, thank you so much for taking the
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  time to be with us on the podcast.
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  Thanks, Jacob. It's good to be here. So
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  Angie, before we dive into everything that we
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  wanna talk with you about, can you tell
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  us a little bit more about yourself in
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  terms of your background in healthcare, and what
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  it is that you're doing today at I
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  three Healthcare Solutions?
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  Sure.
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  You know, I I was thinking about this,
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  and I I realized that I actually started
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  my health care
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  career just out of high school at a
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  couple, you know, ophthalmology office and, another
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  optical store. But the bulk of my health
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  care experience
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  was at a health care payer called Magellan
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  Health in the provider network department. I worked
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  there for nearly 18 years, and I was
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  responsible
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  for many different things over the course of
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  that, the tenure at Magellan in various roles,
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  but all of them in the provider network
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  department.
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  I was in a pseudo technical role, but
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  from a business perspective, not in IT. And
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  I was responsible for making sure that all
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  of our provider data business processes were able
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  to support
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  the ever changing business needs that occur across
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  the country because Magellan was national. We had
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  a great deal of success, and, you know,
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  one of the things that was most critical
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  for us in that department was that the
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  provider data got everywhere, that all the different
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  areas got what they needed, whether it was
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  claims or eligibility
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  or clinical
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  or our provider portal provider directory.
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  And
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  making sure that our providers were well served
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  and things were simple for them, but also
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  that the members' needs were met and all
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  of that.
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  After leaving Magellan, I went to,
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  a company that is now I three Healthcare
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  Solutions
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  and worked in professional service implementing solutions from
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  a consulting perspective
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  for health care,
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  organizations, health care payers,
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  appeals and grievances, that sort of thing. So
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  I I leveraged that in that knowledge,
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  of health care and and expanded
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  my knowledge of of different areas in health
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  care. Today, I'm responsible
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  for the product management for all of I
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  three health care solutions,
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  and our solutions also cover the spectrum of
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  health care payers and providers.
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  We have software solutions
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  for care delivery
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  organizations,
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  small medical practices
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  and, provider organizations,
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  as well as for payer organizations.
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  So we really have
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  that entire spectrum within our portfolio.
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  Fantastic. Well, I appreciate that overview, Angie, and
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  it sounds like you have a lot of
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  expertise
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  in the payer space. So in that vein,
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  I'd I'd love to ask you about a
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  trend that leaders in the payer space have
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  been identifying recently
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  as both a challenge, but also an opportunity.
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  And that's the growing trend as you know
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  of alternative payment models.
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  So Angie, why is it essential for health
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  care payers to become more agile in today's
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  rapidly changing health care environment,
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  and what are some of the ways that
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  you think agility can help payers manage their
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  contracts
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  more effectively?
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  You know, alternate payment models have, you know,
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  been around for
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  almost 20 years now. Maybe it is or
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  10 years now, 15 years almost.
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  They've been increasing
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  in
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  use across
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  health care.
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  And
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  not too terribly long ago, it was about
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  53%
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  for health care. I think it was, like,
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  2019, 2020.
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  53%
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  of health care organizations
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  at the facility level, hospital level, community hospitals
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  had alternate payment models.
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  There has been kind of in the last
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  couple years
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  a trend for
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  health care to actually go down a bit,
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  but there is more pressure from outside organizations
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  like CMS
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  and other organizations
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  to actually increase that because
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  at the end of the day, the the
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  intent and purpose of value based models is
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  to increase the value to the patient,
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  while containing costs in a meaningful way.
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  We know that our health care model today,
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  our health care system is less effective
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  than organizations
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  in other countries and health care systems in
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  other countries.
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  And and I think that was,
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  talked about by
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  in on one of your previous podcasts,
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  doctor Wyatt Decker,
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  with UnitedHealthcare Group. And he he did a
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  really good job, I think, of outlining
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  the challenges in the health care system today
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  and the things that the industry is doing
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  to help that. There are different models of
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  alternate payment contracts
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  that
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  focus on different things, but they all focus
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  on improving value to the patient
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  and better outcomes with patients.
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  Because there are so many different models, being
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  agile is critically important. Different specialties
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  have different needs, different measures.
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  Different organization types will have different needs and
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  different measures. You can't have
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  the same type of
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  performance metrics for a primary care practice that
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  you would for an orthopedic surgeon.
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  So there's a lot of variety, a lot
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  of requirements that need to be met for
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  a
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  value based contract to actually be effective and
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  produce the desired results.
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  Absolutely. That makes complete sense, and I appreciate
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  you referencing that real world example of that
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  interview with UnitedHealth Group's, doctor Wyatt Decker, who,
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  oversees
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  value based care for for what is a
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  very large enterprise.
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  In that vein, Angie, what role do you
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  think technology
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  and new tech tools can play in being
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  more agile and managing
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  those contracts that we just discussed?
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  So when it comes to managing contracts, you
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  know,
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  there's so many different provisions. Those contracts
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  are often templated by payers,
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  but there's provisions in value based contracts that
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  are very different. Things like, what met what
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  are the metrics? What are the measures? What
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  are the obligations of the payer? What are
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  the obligations of the provider organization,
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  what do they need to meet. And and
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  being able to extract that information
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  from the contract
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  and apply
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  the
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  obligations
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  of each party
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  so that they can be managed effectively and
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  proactively
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  needs to be met by technology. Because if
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  you put it in a spreadsheet or expect
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  to be able to read it out of
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  a a word document or a PDF document,
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  you're not gonna effectively manage it and get
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  the desired outcomes from that.
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  So using technology is absolutely critical to just
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  managing the contract itself.
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  But there's some some interesting things that are
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  occurring from technology from a standards perspective
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  With new with the queue HINs and new
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  API requirements that, CMS published recently that have
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  to be met
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  by January
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  1,
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  2026
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  and January 1, 2027,
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  That will actually increase the capability of interaction
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  and obtaining information,
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  aggregating information for both payers and providers,
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  automated,
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  prior authorization, and things like that that will
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  actually
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  having that technology will make achieving the goals
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  of the value based contracts
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  more possible, more feasible, and
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  require,
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  to some degree, less manual intervention
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  to measure
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  the outcomes of that contract
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  so that the providers can be properly reimbursed.
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  And the payers
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  and providers both will be able to be
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  more efficient in accommodating and executing against the
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  terms of the agreement
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  and achieving better outcomes, not only for individual
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  patients, but also for full populations.
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  Understood. So a lot of automation opportunities on
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  the horizon for payers when it comes to
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  managing their contracts.
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  Angie, you mentioned
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  all the different rules and regulations and policy
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  changes coming down the pipeline from CMS. It's
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  a lot for these companies to stay on
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  top of. So from your perspective,
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  what would you say are the 3 key
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  objectives that payers should be aware of right
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  now, and why?
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  So I think, you know, emerging standards
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  have the potential to change that administrative burden.
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  A lot of physicians, though, don't necessarily have
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  access
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  to easily implement technology.
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  They rely on other practices,
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  or other organizations
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  or their software vendors,
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  to actually help them achieve those organizations
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  or those those goals and
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  obligations and standards,
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  especially when you get out of your large
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  health care system. So your your hospitals and
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  your large health care systems,
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  they generally have full IT departments to do
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  that, but your smaller practices
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  have more financial constraints,
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  on them
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  to be able to staff and fund those,
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  especially with
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  increased inflation and and their margins. You know,
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  a lot of data shows their margins are
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  are are reducing, actually.
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  So
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  those those changes
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  cost money from both payers and providers.
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  Providers are gonna be more constrained in their
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  ability to do so. So being able to
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  partner with
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  partner with other organizations
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  to help providers achieve that so that it
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  can be successful
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  is something to to perhaps consider and evaluate
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  and understand that providers may not be able
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  to do that as quickly as payers can.
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  I think that
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  payers also are often burdened with aging technology
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  that is
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  incredibly complex
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  and
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  piecemealed,
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  not always cohesive throughout the organization.
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  But some of the,
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  technology that is being implemented really does cut
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  across the entire organization.
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  Having information available,
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  and and getting modern technology,
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  modern systems for their core business applications
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  will help allow them to be more agile.
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  I think those are some of the key
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  things that need to be evaluated
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  by payers when executing and implementing
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  these technologies and working with the providers
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  to achieve that as well. Having sufficient and
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  advanced notice of when changes will be done,
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  so that providers can keep up.
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  Absolutely. No. It's it's such great advice that
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  payers really need to keep the size and
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  and the capabilities of providers in mind when
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  implementing
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  new technologies. And then, of course, internally for
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  payers, there's a lot of disparate systems that
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  they're often utilizing, and and new and modern
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  platforms will help them, stay a lot more
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  agile as as the landscape evolves.
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  So looking ahead, Angie, what do you see
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  as the next big shift in how health
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  care payers operate, and how should they be
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  preparing for it?
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  You know, I think the standards themselves, those
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  operational standards will have a significant impact
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  on how they interact with providers. And I
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  know I said this, and and I feel
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  perhaps like a little bit of a, you
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  know, repeat.
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  But
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  I I can't really emphasize enough how those
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  operational standards and having APIs between
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  the provider and the payer that are more
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  robust. And with the queue in having more
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  data that is robust
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  can change just operationally how they interact with
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  one another, how they get information that's needed
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  for a prior authorization, how quick that can
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  go if the right information is presented at
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  the right time with having those APIs rather
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  than
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  calling into a call center, asking for it,
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  or going online and submitting a prior authorization
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  than having a clinical reviewer evaluate it. That
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  can be done in more real time. Claims
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  processing can be done more real time, Less
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  human
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  interaction and delays
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  in getting some of those things
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  completed that require a lot of manpower.
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  That's not just technological. That's also operational. I'm
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  looking at the business processes
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  to achieve that.
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  And I think that that that's that's part
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  of what
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  that big shift is going to be. And
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  I don't know that we know what that
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  total impact will be until we start implementing
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  those changes across
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  the entire health care industry.
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  Sure. And it really sounds like everything you
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  just said, it's focused on efficiency. Efficiency of
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  those internal processes for payers.
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  But what else are we missing, Angela? Anything
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  that we that we didn't get to that
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  you'd like to touch on, that our listeners
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  should should really, take notice of?
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  You know, I think that
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  I think there's there's broad understanding and acknowledgment
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  that our health care system is
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  is not as good as it could be.
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  And all Americans suffer from that in some
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  way, shape, or form. It's not just hitting
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  payers. It's not just hitting, cost of care.
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  It's not just hitting providers. It's hitting patients
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  in
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  having
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  providers that there's not enough of them. They
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  don't have enough time because they spend so
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  much time doing
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  administrative work. And I'm really excited to see
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  what
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  will come out of these changes
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  and how that will have a significant potential
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  impact on the quality of care and
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  the disparity
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  of
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  social determinants of health and the disparity of
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  things like, you know, infant mortality and
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  maternal death and things like that. How
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  getting more technology to make providers available to
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  treat more patients
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  will have a profound impact potentially on our
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  entire health care system,
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  improving the health of all Americans.
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  Fantastic. Well, Angie, thank you so much for
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  taking the time to be with us and
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  for sharing your insights with our listeners. We
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  truly appreciate it.
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  Thank you. I enjoyed it.
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  I'd also like to thank I three Healthcare
• 14:04
  Solutions as well for sponsoring this episode. You
• 14:07
  can tune in to more podcasts from Becker's
• 14:09
  Healthcare by visiting our podcast page at beckershospitalreview.com.