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Ready, Set—Help: Health Plan Execs Need Tools For Transformation

Analysis  |  By Laura Beerman  
   March 04, 2024

A new Medecision market report highlights payer UM, CM and population health challenges in 2024.

Healthcare’s key Whats remain dependent on its Hows. Three of those Whats are utilization management, case management, and population health management (UM, CM and PHM). The How is personalization that can improve the care experience while reducing cost and improving outcomes and efficiencies. But personalization in a digital world requires automation and data. Today’s tools and platforms aren’t cutting it, and hope is not a plan.

Large gaps exist between “executives' recognizing the importance of personalization and the current state of implementation.” So notes the press release for a new report from Medecision: The State of Utilization Management, Care Management, and Population Health in 2024. Medecision, a clinical data and analytics platform company, partnered with health consultancy Sage Growth Partners on an independent survey of 53 healthcare leaders from 24 unique organizations.

Health plan CEOs, CIOs, CMOs, and other leaders reported their top barriers to the Triple Aim. Their own systems are part of the problem—preventing cost cutting, better outcomes, and  efficiencies. And while plan executives are optimistic, they can’t reach advanced patient personalization from here. Today’s UM, CM, and PHM needs tomorrow’s technology.

“What health plans need now is a way to transform their utilization management, care management, and member engagement capabilities to drive impact at the health inflection point,” Medecision CEO Kenneth Young tells HealthLeaders.

“Leveraging new technologies that enable strategic use of data to speed decision making, deliver a level of personalization that encourages trust from members, and reaches more members in need of services, will enable health plans to drive down administrative, operational, and medical costs, improve efficiencies, and decrease staff burden.”

The need for personalization, automation and data

Health plan leaders and Medecision see AI-driven automation and diversified data as part of the solution. But first, a key problem.

Among survey respondents, 68% rate inefficient workflows as a top health plan frustration. Limited member engagement tools and the ability to respond to patient needs and in real-time are top barriers.

Three other insights from the Sage survey-Medecision report reveal significant gap —between what health plan executives see as necessary for healthcare transformation and what their current systems and strategies deliver:

  • Personalization: 95% view personalized care management as “moderately important” or “very important”—but only 34% rate their health plan as “very personalized.”
  • Data: 77% of health plan execs believe that it is “very important” to see all touch points for high-risk enrollees—but more than a third say that their plan doesn’t accommodate many of these members (less than 40%).
  • Automation: 51% respond that AI and ML would be “very impactful” on member engagement and health outcomes workflows—but 38% report that their health plan’s current AI/ML tools are insufficient to optimize workflows and increase engagement.

The prognosis?today’s tools are long overdue for an upgrade.”

Fundamental struggles in UM, CM, PHM

“[H]ealth plan leaders are at a turning point, grappling with outdated tech and fragmented data,” notes Medecision’s Young in the report press release. These are the effects:

  • UM lacks data integration and automation, making it hard to use and yielding poor results.
  • CM wrestles with even the most basic technology (e.g., self-scheduling, text messages, digital assessments). This is despite investment an up to 10% administrative spend on CM.
  • Health plan PHM still utilizes traditional data sets (claims, prescriptions). Outdated technologies like faxes are still in high use, representing 47% of leveraged data.

What’s a health plan executive to do?

Medecision recommends:

  • Customizing CM and PHM to personalize the member experience across the health journey.
  • Simplifying processes, minimizing manual tasks, and expediting decision-making through “intelligent automation.
  • Employing strategic data utilization to obtain contextual insights and make more informed UM and CM decisions.

Personalization is the What. Automation and data are the How. Health plan executives believe personalization can have a high impact on desired UM outcomes, including lower unnecessary utilization and costs, and higher program quality.

High-touch personalization must also be compliant across the care continuum. In the Medecision-Sage survey, 63% of health plan leaders rate CM and care coordination tools highly for regulatory compliance.

Laura Beerman is a contributing writer for HealthLeaders.


Current health tech can’t meet the industry’s greatest challenges: poor outcomes, preventable utilization, rising medical costs and a shrinking workforce.

Health plan executives believe member engagement is key to optimizing utilization, case, and population health management.

The problem? They can’t achieve peak personalization with today’s tools and current AI and data limitations.

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