"We do compete against the for-profit nationals and have proven we can win against them," says the executive, who applies her diverse background to advance affordability, provider collaboration, and health equity.
As Dana Erickson approaches her one-year mark as president and CEO of Blue Cross and Blue Shield of Minnesota (Blue Cross MN), she shared with HealthLeaders her vision for better healthcare in Minnesota and the just-minted strategy that is designed to deliver place, plan, and industry-based solutions against healthcare's most persistent problems.
"Was it always my goal? No, I don't think so."
Erickson wasn't gunning to be CEO, but a combination of service, experience, and opportunity—and positions with Optum Health—positioned her for the role.
"I think it was something that did emerge over time," says Erickson, who served in four prior roles with Blue Cross MN before taking the top position.
"What I love about the organization from my whole development perspective—there are many things that I love—was the ability to be involved in so many parts of the enterprise."
She adds: "Certainly [the CEO role] was a part of the conversations I had with leaders throughout my time. It's always that mix of opportunity and preparedness. By nature, I'm a curious person so I've always taken every opportunity I can to learn different parts of the healthcare system. I've worked on the provider side as a nurse, I've worked in public health and home care. All of that work prepared me for a role that brings all of those pieces together."
That background included progressive roles with Blue Cross MN since 2015, including director of Integrated Health Management, senior director then VP of Care Management, and SVP of Health Services.
A first look at the Blue Cross MN strategic plan
Continuity combined with new strategic initiatives are the language of a leader who has spent seven years with a not-for-profit plan—and another decade as a nurse, home health provider, and executive with Optum Health, the health services arm of for-profit UnitedHealth Group.
"I was on the executive leadership team [at Blue Cross MN] and was well aware and very involved with the strategic work that had been done to date," says Erickson. "There are several things in our new strategic plan that were already been in motion. Payment base rate, for example, was part of my prior role. That's certainly something that will continue along with affordability, customer experience, and health equity."
Blue Cross MN shared its new three-year strategic plan, which is focused on five interlocking areas that will advance short-term and long-term goals:
Expanding overall market leadership with growth in all segments.
Growing affordability initiatives to lower the cost of care, including optimization of clinical programs and increasing the level of at-risk claims going through VBC contracts within our provider network.
Advocating for members at every step of their health journey and earning top rankings in industry benchmarks for customer experience.
Paving the way for everyone to achieve their healthiest life by ensuring that company initiatives and priorities are developed, designed, and deployed through the lens of racial and health equity.
Ensuring that the workforce will mirror the diverse membership, with a high-performing, inclusive environment that strengthens their position as a top place to work.
Detailing strategic objectives—starting with affordability
In her conversation with HealthLeaders, Erikson spoke often of affordability—the innovation that, for the most part, has eluded industry progress.
"We are fundamentally, unabashedly focused on affordability because that's what's keeping people from even entering the door," stresses Erickson. "I feel strongly that part of our work on the payer side is getting people access to care."
Erickson adds: "I know that we all love to talk about innovation and advancements, and we need to. But even with the most innovative solution, if it's not affordable, people won't have access to it."
Pictured: Dana Erickson, president and CEO, Blue Cross and Blue Shield of Minnesota.
Working shoulder to shoulder with providers
Erickson identifies to key targets to affordability—deeper, more strategic collaboration that Blue Cross MN calls its joint accountability model, which transcends contracting and financials.
"How do we not just financially collaborate with providers but also find other areas of commonality and strategic alignment that we can work on together. [Access to care and health equity] are a huge driver for me personally, and for the organization."
Erickson adds: "We can help providers be successful in those types of models, but they also have a responsibility and a role to play to be a part of the solution."
A new era of plan-provider collaboration
Perhaps more than ever before, health plans seem keen on provider collaboration. With news that prior authorization practices contribute to workforce burnout and shortages, payers are wise to treat providers as partners.
Noting pervasive and increasingly high-cost workforce challenges, Erickson adds: "We're at a point where we don't have enough clinicians to sustain the prior model. We have to move away from contractual relations and toward strategic partnerships—having like-minded providers that want to help us collectively address these systemic issues."
For Erickson, enhanced collaboration is personal.
"Collaborating with providers is a focus of mine. It's really driven out of my background of actually providing direct patient care and working in public health. Providers are a key part of the ecosystem, but they can't solve healthcare's issues alone."
Access to care: the first customer experience threshold
Innovation is irrelevant if you can't afford a health plan's gateway offering: coverage.
"I believe that part of our mission is getting people access to care," says Erickson. "So many people have a barrier to even accessing care and knowing where to go. The advocacy piece becomes critical."
Once people are in the door, a combination of customer experience, provider collaboration, and technology help create a loyal health plan member.
"A personalized approach to healthcare is an expectation that consumers have now," says Erickson. "Probably 10 years ago, it was about customization. Now it's about personalization. How do we how to make that experience personalized and specific to them to get the best outcomes possible?"
The CEO adds: "The use of technology has changed the expectation. Our ability to partner with providers on that type of care is critical. All of that has to be done within a payment model that supports that. Then ask, 'How can we provide better data and analytics? Where are we duplicating efforts and working against each other?'"
Erickson ends the topic with: "You have to really remember that the patient is the goal here."
Serving at ground zero
Even with the patient as the goal, not all patients facing life's storms are in the same kind of rowboat.
"It's something that motivates me on a daily basis," says Erickson. "I pull on the experiences I had as a home health nurse, of walking into people's homes and seeing that all of the equipment that we thought was going to change their life that was ordered in the doctor's office was sitting in the bathtub. And that happened on multiple occasions. Or refrigerators that were empty when I opened the door."
Flash forward to 2020. As the pandemic was emerging, Minneapolis was in the spotlight for a different kind of inequity—the treatment of black Americans by the police.
"We came out of ground zero for George Floyd's murder," Erickson makes it a point to discuss. "It was important for the whole community to come together out of that crisis."
That wasn't the last crisis. As The Independent wrote in April 2021:
"George Floyd and Daunte Wright never met but there's a chilling overlap between the two men. They died within 11 miles of each other. Mr. Floyd on the south side of Minneapolis and Mr. Wright in Brooklyn Center to the north of the city." Brooklyn Center, the "first-ring suburban city … in the Minneapolis-Saint Paul metropolitan area," became a priority response site for Blue Cross MN.
"We in the Twin Cities came out of ground zero for George Floyd's murder," says Erickson.
"It was important for the whole community to come together out of that crisis. Then there was another police-involved shooting, Daunte Wright. We then specifically had a call with city officials in Brooklyn Center and our leaders jointly determined a strategy that we call place-based initiatives."
Erickson adds: "Solutions come from communities. That's our belief. We need to listen to the community tell us what they need versus us coming in an applying what we think."
Those solutions include TurnSignl, a new app providing on-demand and real-time legal services to de-escalate encounters between motorists and law enforcement, as well as no-cost access to culturally responsive and trauma-informed teletherapy through Hurdle Health.
Regarding equity, Erickson ends with: "It is the right time for the healthcare system. Collectively it's about combining our efforts around a common pain point."
The revisions span multiple populations and conditions while addressing social determinants.
As the National Committee for Quality Assurance (NCQA) advances digital quality measurement (dQM), it will continue publishing its print-based measures manual—the Healthcare Effectiveness Data and Information Set (HEDIS)—which has just been updated for 2023.
NCQA made 14 updates spanning measure additions, reductions, and more.
New HEDIS measures
The following first-time metric names and descriptions are quoted verbatim for full accuracy:
Oral Evaluation, Dental Services (OED). Medicaid members under 21 years of age who received a comprehensive or periodic oral evaluation with a dental provider.
Topical Fluoride for Children (TFC). Medicaid members 1-4 years of age who received at least two fluoride varnish applications.
Deprescribing of Benzodiazepines in Older Adults (DBO). Medicare members 67 years of age and older who were dispensed benzodiazepines who achieved a ≥20% decrease reduction in benzodiazepine dose.
Emergency Department Visits for Hypoglycemia in Older Adults with Diabetes (EDH). For Medicare members 67 years of age and older with diabetes (types 1 and 2), the risk-adjusted ratio of observed to expected emergency department (ED) visits for hypoglycemia.
NCQA increases focus on social determinant screening, intervention, and data
The agency added a fifth new measure, name and description:
Social Need Screening and Intervention (SNS-E). Members who were screened, using prespecified instruments, at least once during the measurement … and received a corresponding intervention if they screened positive.
Screening is a growing focus of health equity efforts. The NCQA has prioritized food, housing, and transportation for the new SNS-E measure, with a corresponding focus on intervention with one month of need identification.
The agency has also added race and ethnicity stratifications to eight more HEDIS metrics:
Immunizations for Adolescents, Asthma Medication Ratio, Follow-Up After Emergency Department Visit for Substance Use, Pharmacotherapy for Opioid Use Disorder, Initiation and Engagement of Substance Use Disorder Treatment, Well-Child Visits in the First 30 Months of Life, Breast Cancer Screening, and Adult Immunization Status.
The NCQA states that it "plans to continue expanding the race and ethnicity stratifications to HEDIS measures over the next several years to help identify disparities in care among patient populations."
The NCQA states that it will "explore additional opportunities to transform HEDIS measures to be more inclusive and affirming of sexual and gender minority members." In its 2023 measures update, this included an update that "pregnancy and childbirth are not experienced exclusively by individuals who identify as women [to] … reduce the likelihood of transgender members are inadvertently excluded or inappropriately included in a measure due to gender identity."
Retired HEDIS measure
The agency has retired the following metrics, names and descriptions:
Annual Dental Visit (ADV): This measure focused on access to dental care, rather than quality of dental care.
Frequency of Selected Procedures (FSP)
Flu Vaccinations for Adults Ages 18–64 (FVA),Flu Vaccinations for Adults Ages 65 and Older (FVO),Pneumococcal Vaccination Status for Older Adults (PNU)
Measure requirements and reporting updates
The NCQA will continue promoting existing measure digitization—i.e., Electronic Clinical Data Systems (ECDS) reporting—during the multi-year transition to dQM, an approach that will be more automated and comprehensive.
Two 2023 changes focus on women's health. Voluntary ECDS will be permitted for the Cervical Cancer Screening measure while electronic reporting will now be required for Breast Cancer Screening.
A broader change to support digital measures will make optional measures exclusions required.
The agency's chief product officer identifies first milestones and timetables in the transition from paper-based to digital quality measurement.
The NCQA's conversion of its printed quality measures manual to a software solution that supports digital quality measurement (dQM) is under way.
The pilot includes six payer, provider, and tech organizations, counts former ONC national coordinator Dr. Don Rucker as an executive lead, and will benefit from new CMS recognition that digital quality must move beyond paper-based standards and EHR-only data rooted in manual processes.
For the first of a three-part series on the pilot, HealthLeaders interviewed NCQA chief product officer Dr. Brad Ryan about why the pilot is unique as well as vital for continued healthcare transformation and value-based care (VBC) progress.
NCQA pilot overview
The Digital Quality Solutions pilot targets the NCQA's printed manual of HEDIS measures—the Healthcare Effectiveness Data and Information Set that the agency updates annually and uses, in part, to generate health plan ratings.
The pilot is unique in several ways.
"This is the first time that we have developed software as a primary product," says Ryan.
An NCQA press release adds two other pilot differentiators: "First, it uses 'agile' software development techniques that emphasize frequent iteration and steady input from users. Second, the project involves a range of organization types—helping diversify NCQA beyond its roots as a quality evaluator of health plans and physician practices."
Diverse stakeholder participation is another new facet.
"We know that our HEDIS measures are getting used by organizations outside of the vendors and plans," says Ryan. "Provider organizations have value-based contracts, and this is a part of quality, but we haven't always engaged those parties so we're trying to do that for now for those delivery systems."
dQM market value and dynamics
As a printed publication, the NCQA's HEDIS manual binds quality measurement to a paper-based process which a cottage industry of vendors individually interprets and programs.
"You have teams of people who are clinically technical who take that paper specification and interpret it with their brain to put it into pure SQL or SAS or some kind of environment to turn it into a HEDIS engine," explains Ryan.
"That is being done by 100 different vendors, development teams, infrastructures, and data models," he adds, to make HEDIS computable.
The NCQA pilot will remove the repeatable manual processes of multiple vendors—"giving them an opportunity to revamp to a lower-cost model," says Ryan, through HEDIS software that will be modular, configurable, and more efficiently computable.
For these reasons, Ryan asserts that the NCQA software complements rather than competes with current HEDIS vendor offerings, with the agency acting more as a channel partner.
"I think the vendor community should be excited because it's an opportunity to evolve their business model."
Since pilot launch, stakeholders have held initial meetings and the NCQA announced an in-development, digital transition playbook at its July Digital Quality Summit. The organization plans to preview its software by December 2022 and make a pilot product available to early adopters. That product will include a dQM subset aligned with the most common VBC measures.
"We'll be running two models [printed and dQM] for some time," says Ryan, adding that the NCQA wants to be all digital within the next four years.
"The transition is the hard part. We know partial dQM will be a challenge. The early adopters are those that would like to start learning, investing, and building out the infrastructure to support the new model earlier."
Transforming business models and tech approaches
Ryan acknowledges that quality has needed to migrate from a measurement to an improvement model to keep up with other kinds of healthcare transformation.
"There has been rapid change in terms of how healthcare is structuring itself. Older products fixed to more traditional care models," says Ryan, citing VBC, risk management, and emerging delivery systems rooted in telehealth.
"One of the things we're working on is how we can be more flexible to emerging business models. All of this been happening to some degree but through hard, friction-filled, wasteful effort," says Ryan. "There is an enormous opportunity to take both our existing portfolio of paper and people-based standards … and rethink what an assessment looks like in a digital world."
Even Ryan's chief product officer role is reflective of organizational and industry change. The NCQA created the position and hired Ryan for it in 2020. From the beginning, his objective was clear.
"We have an incredible opportunity to lead the transformation to deliver better measures to create more relevant insights at the point of care, ease the administrative burden for clinicians, and all at lower costs," said Ryan upon joining the NCQA.
CMS alignment will support dQM efforts
Before dQM, there was eCQM: Electronic Clinical Quality Measures. While eCQM still represents a step forward in the evolution from paper to digital quality, it has limitations. It is based on the EHR with manual processes still required for mapping data and updating clinical workflows. dQM is based on standardized data, including FHIR standards, that allow for automated data mapping, collection, and extraction. In addition, dQM data can be pulled from anywhere (e.g., patient registries and surveys, HIEs).
"In the time since we conceived of and launched the pilot, we have more alignment with CMS on dQM. They've started communicating a definition and benefits that align with pilot content," says Ryan, adding that CMS also recognizes the need for the kind of "dynamic, configurable software component" that his organization is building.
Examining key eHealth stats, Washington Post legislation analysis, and whether near-term inflation relief is a reality.
Medicare beneficiaries aren't just worried about the impact of inflation on their medical costs. They fear that even a small increase would make their premiums and prescriptions unaffordable.
These are the latest results from a survey of 2,500 Medicare beneficiaries who purchase coverage via eHealth, one of the nation's first and largest health insurance exchanges.
And while the July 2022 eHealth report puts a compassionate fine point on the effect of financial fears—which impact people's everyday lives as well as that fever chart we call the stock market—what impact do certain medical costs actually have on inflation? A Washington Post analysis tackled these questions, citing a wealth of sources—some of whom are trading intellectual fisticuffs.
Healthcare inflation fears mount
eHealth's survey highlights include the following:
Inflation's effects are both a future concern and a current reality.
95% of survey respondents are worried about rising healthcare costs.
45% indicate they've seen inflation's impacts already.
Two concerns weigh on consumers' minds more than any.
65% of respondents were equally concerned about Medicare Part B premiums and prescription drug costs.
60% were worried about rising copays and deductibles.
Unaffordability is dangerously close.
49% of Medicare beneficiaries would not be able to afford a Medicare premium that increased by 10% or less.
52% answered the same about prescription drug hikes.
Seniors are looking for immediate relief, but legislation will not bring it.
88% would welcome sooner-rather-than-later drug cost reductions to ease inflation fears.
86% want the government to play a role, specifically for Medicare to be able to engage in direct negotiations with drug companies.
But what would be the effect? And to what degree and how quickly can drug price bill legislation—if passed—impact either inflation or medication costs?
Drug cost impacts on inflation: Yes or no?
The aforementioned Post analysis states: "On the face of it, the latest U.S. government report would suggest prescription-drug costs are not a big part of the inflation problem." For proof, the article cites the following:
Drug price inflation pales in comparison to the overall. The Bureau of Labor Statistics reports that prescription drug prices grew at a far lower rate (2.5% since June 2021) than overall prices during the same period (9.1%).
A small number of drugs account for the most spending. The Congressional Budget Office reports that while 90% of prescribed drugs are generic, brand-name drugs generate significant spending.
This is also true for Medicare. Two Kaiser Family Foundation studies show the same discrepancy in Medicare Part D (7% of covered drugs equal 60% of net spending) and Part B (8.5% of covered drugs total 80% of spending).
Where things get dicey—and sources contentious—is the subject of brand-name drugs, also covered in the WaPo article:
"Brand-name prices are high and rising." This according to a recent JAMA study.
No, they're not. The Pharmaceutical Research and Manufacturers of America (PhRMA) cites data from multiple sources that "the trend on drug prices is not skyrocketing." PhRMA takes issue with the JAMA study, claiming that it "completely ignores savings that are generated within the system as a branded medicine overtime becomes generic or biosimilar products that lead to lower costs for patients and society."
Yes, they really are. JAMA study co-author Benjamin Rose rebuts the rebuttal, noting that "generic savings only occur after drugs have a period of market exclusivity."
They said, they said—but what do Congress and the Biden administration say?
Enter the drug price bill
A pending Senate bill would allow Medicare to negotiate select drug prices and require manufacturers to pay Medicare a rebate if the price of their drug outpaced inflation. The Biden administration backs the bill, claiming it "will not only lower the cost of prescription drugs and health care for families, it will reduce the deficit and help fight inflation."
The Post analysis pokes holes in this claim, noting that Medicare's new negotiating power would apply to only 10 drugs (20 initially), with the first impacts not felt until 2026. As to the rebates, if inflation continues to remain above drug price increases, few would be offered and not until 2023 at earliest.
A Post source at the Committee for a Responsible Federal Budget concludes that "not much of the effects of this particular bill take effect in the near-term. So over the next couple of years, it's probably doing more to help prevent inflation from bleeding into drug prices (and then bleeding back into inflation) than from cutting inflation outright."
The Post's fact checker feature ends in a draw, acknowledging potential savings on the highest-cost drugs but leaving the debate open as to how much brands are to blame—and leaving consumers with their same inflation concerns.
All of the tech asks from the agency’s new Medicare Advantage (MA) request for information (RFI).
To paraphrase the well-known children’s book, 2022 has been a terrible, horrible, no good, very bad year for MA.
Not in terms of enrollment growth and carrier profits, mind you. But the PR has been dismal—noting that MA plans are overpaid, that prior authorization (PA) requirements contribute to healthcare staff burnout, and, according to an OIG report, that medically necessary services that fall within PA coverage rules are often delayed or denied.
Now, CMS has released a RFI asking MA plans how they can make the program more equitable, accessible, innovative, affordable, and collaborative.
The use of data for MA plan and program improvement is peppered throughout the RFI. Specific and detailed asks concern what plans can do—and what CMS can do—to better leverage data for better outcomes.
Data sought for every objective
The best data to advance equity. CMS seeks better data related to race, ethnicity, and language; sexual and gender identity; people with disabilities and language/communication hurdles; cultural identity and religious preferences; socioeconomic need; and people in rural and underserved communities.
A focus on socioeconomic data. CMS adds specific questions, including MA plan challenges in “obtaining, leveraging, or sharing such data.”
Supplemental benefit use and outcomes. To improve both, CMS asks what “standardized data elements” it could collect and how they would also aid DOH, equity, and cost-sharing burdens.
Applications for utilization management (UM). With a Senate bill aimed to improve PA headed to the house, CMS wants to know which of its data, if any, help with UM/PA application and how MA plan data could align for better efficiency.
Value-based contracting. Data to assess VBC models within the MA program.
Competition dynamics. CMS seeks data on vertical integration and its MA market impact.
Multiple questions on data exchange and interoperability
For its “Drive Innovation to Promote Person-Centered Care” pillar, CMS specifically asks:
What are the key technical and other decisions MA plans and providers face with respect to data exchange arrangements to inform population health management and care coordination efforts?
How could CMS better support efforts of MA plans and providers to appropriately and effectively collect, transmit, and use appropriate data?
What approaches could CMS pursue to advance the interoperability of health information across MA plans and other stakeholders?
What opportunities are there for the recently released Trusted Exchange Framework and Common Agreement to support improved health information exchange for use cases relevant to MA plans and providers?
CMS seeks algorithmic intelligence
Healthcare algorithms—understanding them and regulating them—are a growing focus for CMS. In its MA RFI, the agency seeks detailed information on MA plan algorithms, including:
The algorithms used to identify in-need members
Algorithm prediction targets, such as cost and utilization
Algorithm testing and bias related to differential outcomes and how plans mitigate
Differential test function, validity, independent evaluation, and reporting
Tech was certainly not the only focus of CMS’ MA RFI. Other components, including health equity, MA plan design, VBC, and market dynamics, will be addressed in depth in the future.
The request for information aligns with CMS' Strategic Pillars.
CMS released a request for information (RFI) that seeks "feedback on ways to strengthen Medicare Advantage (MA)." The goals are to align MA with CMS' Vision for Medicare and its Strategic Pillars through increased and diverse stakeholder input.
In a related press release, CMS administrator Chiquita Brooks-LaSure stated: "Medicare Advantage is a critical part of CMS' vision to advance health equity; expand access to affordable coverage and care; drive high quality, person-centered care; and promote affordability and sustainability of Medicare," adding: "Medicare Advantage plans are essential partners in this work."
The agency seeks other partners as well.
Dr. Meena Seshamani, the agency's deputy administrator and director of the Center for Medicare, added: "We see a huge opportunity for partnership with as many stakeholders as possible to better understand how care innovations are changing outcomes and costs and how Medicare Advantage is working for enrollees."
The following summarizes RFI components, with future articles planned that investigates each in more depth.
Five RFI objectives
The RFI components include the following details:
Advance Health Equity. CMS seeks "examples of policies, programs, and innovations," related to:
screening, documentation, and services related to the drivers of health (DOH; also known as the social determinants of health, or SDOH) care gaps
type, source, and use of both data and algorithms to identify need while preventing bias
specific DOH services, including food/nutrition and physical activity
contracting with community-based organizations
Expand Access: Coverage and Care. The agency requests information on plan:
marketing, education, and plan shopping/selection
telehealth approaches
network adequacy
supplemental benefit design
utilization management and prior authorization
Drive Innovation to Promote Person-Centered Care. CMS focuses on MA plans and value-based care (VBC)—including provider and patient experiences, model design, trajectory, preferences, and outcomes—as well as what the agency can do to improve and plan response to CMMI resets.
Support Affordability and Sustainability. CMS seeks input on payment, risk, and MLR methodologies.
Engage Partners. CMS seeks ideas to increase stakeholder collaboration for individual, community, and systemic benefit.
While distinct from CMS rulemaking, similar parameters apply to RFI responses including a 30-day public comment period from date of publication. August 1 is the RFI's official publication date, making the comment window open until August 31.
AHIP webinar targets the need for payer-specific customer experience platforms and an ROI path where low-hanging fruit precedes clinical targets.
AHIP’s latest webinar—“Get Back to Basics: CX Lessons from Members and Health Plans”—takes its title from surprising data: that the health plan call center is still king for customer experience (CX) and can be a source for wins before targeting more complex clinical objectives.
This from Zipari, the webinar’s sponsor and “the first and only CX platform build exclusively for the health insurance industry” per the company’s website. Payers’ unique challenges were another webinar focus, along with the importance of CX platform decisions that start with strategy to deliver on concrete objectives.
The data cited below originates from health plan and member surveys conducted by Zipari, whose webinar speakers included Maryann Waugh, senior content marketing manager, and Kristin Daniels, director of product. Waugh and Daniels identified the following four components of platform strategy:
1. Start with strategy
“Don’t start looking at apps, portals, and platforms until you have your strategy,” says Daniels.
Her colleague Waugh cites the fundamentals that members are looking for from their health plans—specifically that 42% are looking for more education and support and through various forms of communication.
“A successful CX strategy needs to be aligned with tactics that are based on members’ needs, and knowing how they prefer to communicate,” says Waugh, adding: “This is also the type of information that health plans really need to combine with members’ clinical profiles, to be able to develop an engagement strategy that will work for their particular population.”
While clinical targets were a recurring theme, Waugh and Daniels stress that they may not be the best place to start when it comes to a payer’s CX platform given their next recommendation.
2. Tie everything back to the service center
Zipari data shows that 45% of health plan members still prefer using the call center for help, with Waugh noting: “I've actually been a little surprised at how important the call center has remained to members.”
She adds: “We tend to expect older generations, which is most of Medicare, to prefer the phone. But then we assume that younger generations only want to interact digitally. But we're actually seeing that pretty consistent demand for the call center across all generations and across all health insurance market segments.”
Zipari cited the following data on call center preferences to support:
41% of employer-sponsored plan members prefer to use the call center.
42% of individual commercial members indicated as such.
51% of both Medicaid and Medicare plan members also rely on the call center.
Waugh and Daniels note that call centers can be a source of “quick wins” before more advanced CX ROI targets are met.
“The number of customers who are setting communication preferences or registering for the member portal would be a great simple goal to focus on for a health plan. While the relative value might be lower, members completing that goal will open up additional ROI opportunities,” says Daniels.
She adds that these goals and their data “don't require population segmentation, not even for gender” and that while health plans are collecting this low-hanging fruit, they can be “working behind the scenes on the API or batch connections that are needed to link more of the clinical data sources and behavioral data to the CX platform to enable future goals.”
3. Select a CX platform optimized for health insurance
“Why can’t my health plan CX be like my bank’s?” The webinar answers what members may be asking by citing unique health plan challenges—diverse customers, regulation, legacy tech, and unique healthcare workflows—and then identify management, configuration, analytics enablement, and centralization needed to answer them.
“Tech teams at health plans are always fighting uphill battle,” says Daniels, citing the competition between launching new projects and supporting existing ones—a classic disruptive innovation struggle.
Waugh also cites workforce competition: “There’s always that one person who was the only one who really knew a legacy system or process. And that person will get some amazing job offer across the country, move away, leave the organization, and every project will get months behind.”
4. Focus on measurable goals
“Figuring out what to do first can still be very daunting for a health plan,” says Waugh. “It can also be really easy to conflate strategy with tactics.”
She recommends health plans take a “stepped approach,” with responsibility shifting as goals move from low to high value:
Small but quick wins. Communication preferences and member portal registration, targeted by Marketing and Customer Experience teams.
Medium value begins to shift to from Marketing to Clinical teams. This category includes paperless communication and PCP selection.
Achieving the highest value once the groundwork is laid. New CX platform goals link to Clinical teams in such areas as increased member screenings and chronic care management enrollment.
According to Zipari, the good news is that health plans are seeing a direct connection between their CX platforms and the following “digital wins”:
93% credit their platforms for membership growth.
Close to 85% believe CX platforms helped improved their CAHPS and NPS scores.
73% believe member churn decreased due to digital resources.
Waugh notes: “Health plans are dealing with a number of high-impact factors both in the marketplace and within their own organizations. Externally, they're dealing with red-hot competition, pressure for digital adoption and self-service. Many of those demands coming right from consumers themselves, as well as the normal pressures around regulatory compliance and quality concerns.”
Citing internal dynamics such as “structure, history, and budget,” Waugh adds: “And then in the middle is the member who just wants you to make it easy, consistent, and on demand.”
John Baackes is the right leader at the right time and a staunch physician advocate.
"L.A. Care Health Plan started as an experiment."
So began John Baackes' exclusive interview with HealthLeaders, spanning milestones from the local plan's 25th anniversary to still-emerging initiatives designed to strengthen the safety net for all.
A board member of multiple organizations including AHIP, Baackes is nearing the eight-year mark as CEO of a plan that makes non-mandated expansion part of its business model and has become one of the few de facto public options operating in the U.S. as federal reform languishes.
Those accomplishments alone would make for an impressive 25 years. Instead, L.A. Care added two major announcements to its silver anniversary celebration on July 22nd, both related to Elevating the Safety Net—a multi-strategy initiative launched in 2018 to address L.A. County's physician safety net shortage.
The first milestone: L.A. Care has hit the $100 million mark of a $155 million funding commitment made in 2018. The second is the next round of scholarships tied to the initiative's primary objective: creating the next generation of L.A. County primary care physicians (PCPs), with an emphasis on opportunities for people of color and women.
The safety net needs a safety net
L.A. Care's Elevating the Safety Net includes four interconnected components that address multiple market dynamics.
Building the physician pipeline. Eight need-based annual scholarships divided between two medical schools (David Geffen School of Medicine at UCLA and Charles R. Drew University of Medicine and Science), awarded based on the scholars' expressed desire to work in underserved communities.
Baackes: "Of the 40 scholarships given out, all but two have been given to students of color and half of them are women." The first of these students graduated in May 2022.
Supporting practice sites. Funding adds new, locally based PCPs, with recruitment and loan repayment incentives that help clinics compete with Kaiser Permanente and AMCs.
Baackes: "We've been able to give these practices a $305,000 benefit that they wouldn't have had. Since we started in the fall 2018, 142 doctors are here practicing in L.A. County that were not here when the program started."
Funding residencies. L.A. Care has funded 14 primary care residencies designed to keep people practicing in county.
Baackes: "These are attached generally to teaching hospitals and again build a pipeline of people who will stay in L.A. County and serve the network."
Caregiver training to support union-associated home care workers. Funding to train family caregivers of members of the Service Employees International Union (SEIU), one of L.A. Care's covered populations.
Baackes: "We were noticing that 90% of the time, the beneficiary selects a family member who may have absolutely zero training … One of the students [his mother's caregiver] said 'The program taught me the difference between my role as a son and my role as a caregiver and as a result, I'm better at both.'"
Pictured: John Baackes, CEO, L.A. Care Health Plan.
For Baackes, it's not just about how many serve the underserved. It's about who they are. Elevating the Safety Net is cultivating new generations of PCPs and caregivers who look and speak like their patients. Baackes has shepherded the initiative from inception to lengthening impact.
"I've just gotten the Board of Governors to expand the program for another five years," Baackes told HealthLeaders.
"The amount of money that we set aside the first time, which is 5% of our reserve for five years, created the fund of $155 million. We have enough money left in it to keep the program going for another five years. So we're not asking the Board to divert additional reserves to this program. It's established funding."
Baackes and his board are keeping long-term funding flowing for Elevating the Safety Net because they are acutely aware of a significant area where the money lags: reimbursement rates for PCPs.
Combating the two-tiered reimbursement system
Difficult, low-paying jobs have trouble attracting and retaining workers. Unfortunately, what is true of the retail and hospitality industries is also true of PCPs, particularly those with underserved populations. Surprisingly, reimbursement is even worse in the Golden State.
"California is in the bottom 10 states in terms of the amount of reimbursement," says Baackes, despite being the highest taxed state in the country.
The answer? A new Baackes-backed initiative.
"We've organized an effort here that I'm calling the Los Angeles County Safety Net Coalition. We're trying to bring together the hospitals, the doctors, and the clinics and come up with a proposal for Medi-Cal reimbursement reform where we would offer the legislature a package that we think would begin to resource Medicaid in the way it needs."
Noting that Medicare and commercial reimbursement rates essentially subsidize Medicaid while making it less attractive for providers to participate, Baackes adds: "It's not sustainable. You're really creating a two-tiered system."
"We have accepted every opportunity over our history to expand service delivery"
L.A. Care Health Plan was founded in 1997, the same year as Medicare Advantage and the Children's Health Insurance Program.
"When L.A. Care started, there was no infrastructure here," says Baackes. To serve members, the plan:
first subcontracted to multiple commercial plans
began to contract directly with hospitals and independent practice associations (IPAs) after in 2006
expanded to cover seniors, people with disabilities, and ACA Medicaid expansion populations
Today, L.A. Care also covers Medicare beneficiaries who are dually eligible for Medicaid.
"We were the only local initiative plan that opted to get into Covered California," says Baackes, who adds that L.A. Care also meets the ACA's public option definition.
In some ways, the plan reflects characteristics that are unique among states. California is the only state with a multi-model Medicaid program, including the local initiative approach that LA. Care chose. The plan covers 2.7 million members, more than some states. That number now includes Medicaid coverage for residents who are undocumented.
Says Baackes: "We have tried to add value, both to our providers and to our members, through a series of initiatives that go beyond what we're required to do under our contract as Medi-Cal managed care plans under the Department of Health Care Services."
Amplifying connection and reach
This value includes L.A. Care's Resource Centers, which offer health and wellness resources to members and the general public.
Baackes notes that "few other plans have these centers," which were vital during COVID-19 and are another example of the plan's commitment to expansion from an initial four to now 11, with another three planned by 2023 aided by $74 million in funding from BlueShield Promise, another Medi-Cal MCO.
The expansion of the centers—now co-branded with BlueShield of California Promise Health Plan to reflect their partnership—is to include larger centers with member-only services such as technology bars for virtual care appointments and services delivered by co-located social service agencies.
L.A. Care will now offer more services thanks to CalAIM, a five-year Medicaid demonstration that launched January 2022 with a focus on integrating clinical and non-clinical care.
"We're going to work very closely with the state. There are several layers to it and it will probably take two years before all of the programming is turned on, but we think it's beginning of a step in the right direction."
It is part of the forward progress that Baackes is making—to lead L.A. Care as a hyperlocal plan that delivers equal measures of systemic change.
Aaron Gani's virtual reality venture includes payer solutions for behavioral health "meta comorbidities."
"I've been a technology nerd my whole life. I have always worked in technology, creating new applications and experiences."
The desire to take this further and create his own business led Aaron Gani to leave his role as Humana's CTO and found BehaVR, a digital therapeutics (DTx) company applying "the neurological power of VR" to curb anxiety disorders and chronic disease at scale.
"I had always wanted my own business and just couldn't not do it anymore," says Gani, adding: "Which is the only good reason to start a business."
Gani's technology advancement work at Humana—"looking into the future and thinking about how various technologies would impact the things we could do to understand and improve our members' health"—put behavioral health and VR on his radar. The result is a problem-solution-market fit that, for many health tech startups, now includes payers among its B2B target segments.
The problem side
Behavioral health "meta morbidities" are Gani's focus.
"Because of my role at Humana, I had become aware of this cluster of things that so many people are dealing with around stress, anxiety, depression, chronic pain, and substance use disorders. It's this big comorbid bundle that is connected with a whole range of other chronic conditions."
Gani, also BehaVR's CEO, targets both the human and industry sides of the problem.
"Where there's so much pain and suffering, there's also so much extra consumption of resource in the healthcare system. It's a huge opportunity to improve lives and unlock value."
"For me," he adds, "that was the right problem to tackle."
The solution and market sides
"Initially, it was just a hunch but as I dug deeper, I found ample evidence over a 20-year period of the unique neurological advantages of the VR medium," says Gani, who explains how the technology works.
"Everything we do on a 2D screen—whether it's a smartphone, a laptop, a big screen TV, or an IMAX theater, it doesn't matter—your brain processes all of those in essentially in the same way, which is it's not happening to you; you're just looking at it," he explains.
VR is completely different.
"We're replacing your sensory inputs, primarily visual and auditory. The only way your brain has to process that simulation is as a new reality," he adds. This involves activating the brain's fight-or-flight mechanisms and eliminating distractions to trigger arousal (exposure therapy) or calming responses.
"That is really powerful when you apply that to mental and behavioral healthcare."
Gani believes that these benefits align with multiple industry tailwinds, including the rise of tech-enabled healthcare consumerism and digital fitness.
"Fitness in VR is exploding. A huge chunk of Meta's App Store revenue is driven by fitness. And it is the most retentive application or type of experience in VR. People spend more time in VR doing fitness than gamers do."
Other tailwinds include better, more accessible VR technology and a growing interest in the metaverse.
"This kind of metaverse moment that we're all living through, it's not a surprise to us in this company," says Gani.
Using the wellness market as an entry point
There are also headwinds, including what are still the early days of both VR and DTx uptake. But BehaVR is focusing on multiple therapeutic areas and commercialization pathways to account for them.
The company has used VR wellness products as an entry point to gather the real-world evidence (RWE) that payers and other prospects want, including from DTx. "VR wellness products cast a very wide net and help a lot of people at a very low cost," says Gani.
He adds: "If you're going to expect people to adopt your solutions in the healthcare space, you better be evidence based—you better design your products from proven science and be prepared to prove outcomes."
Current BehaVR products include NurtureVR and PNE+ (Pain Neuroscience Education+). NurtureVR is an immersive maternal health and wellness program "designed to support expectant moms and their families through the third trimester, labor and delivery experience, and postpartum phases." PNE+ targets pain management through a "progressive and personalized program designed to help physical therapists reduce patients' Pain Catastrophizing Score."
Delivering clinical and cost outcomes
NurtureVR and PNE+ do not rise to the level of prescription digital therapeutics (PDTx) nor do they require clearance from the Food & Drug Administration (FDA). This was intentional on BehaVR's part.
"Starting with wellness allowed us to iterate, to leap between platforms quickly and build learning into the dataset as the [VR] technology is becoming more consumer grade, low cost, and highly available," notes Gani.
He adds: "Randomized controlled trials (RCT)—which are really just tables takes to demonstrate safety and efficacy—are not necessarily enough to convince the key decision makers, whether it's clinicians or payers, that your program should be adopted. You have to go beyond that to real-world evidence of clinical effectiveness."
"Beyond that, particularly for payers now, you need to show economic outcomes and savings. I think that's reasonably well understood in the DTx space. You've got to do it, and there are no shortcuts. It's one thing to prove some set of endpoints in an RCT. But what about outcomes over six or 12 months? Does your solution really change lives in a way that's persistent?"
Expanding clinical partners and pathways
"We built all of our programs with great clinical partners who have a lot of domain expertise in the space," says Gani. "It's about how you meet the market in terms of clinical design and utility, as well as commercialization models and go to market."
These partners include Confluent Health for BehaVR's chronic pain programs; Dr. Eric Garland and his proprietary intervention M.O.R.E (Mindfulness-Oriented Recovery Enhancement) for opioid misuse and chronic pain; and Sumitomo Pharma for anxiety and depression.
"We have a very deep partnership with Sumitomo to jointly develop and commercialize our anxiety and depression therapeutics—starting in the US, but ultimately around the world."
The partnership reflects the iteration of BehaVR's wellness products base and its approach, as the Sumitomo products for Social Anxiety Disorder, Generalized Anxiety Disorder, and Major Depressive Disorder will require FDA clearance.
"Now we're ready to go down these FDA pathways that ultimately require a lot more structure, rigor, and careful change management," says Gani.
The press release for the partnership adds: "The intent of these three products, in this collaboration, is that they will be classified as a Software as a Medical Device and will fall under the FDA regulatory framework that supports innovation and commercialization of digital tools while protecting patient health."
"There's not one right way to do this," says Gani. "There are some PDTx companies that have only brought products to market through the FDA pathway. Then there are others—BehaVR is in this group that have chosen to develop products that steer clear of making any claims about treatment, cure, and prevention in order to get out into the market and get real consumers and clinicians engaged."
Gani adds: "Getting data drives learning. If you jump straight to an FDA-cleared pathway, you're missing out on that opportunity to get a lot more people involved and iterate very quickly on product design and engagement."
Of the 12 states that have not expanded their Medicaid programs, four have taken legal, legislative, and/or budgetary actions this year with varying results.
The Kaiser Family Foundation (KFF) has updated its state Medicaid expansion tracker, highlighting 2022 activity through July. The following summarizes activity in both expansion and non-expansion states.
In January 2022, Georgia sued CMS and HHS for withdrawing its December 2021 1115 waiver approval, which had included Medicaid work and premium requirements. While Georgia had expanded Medicaid coverage in previous years, it was not a full expansion and was contingent upon the now-disapproved requirements.
From January-February, Kansas’s Democratic governor took two actions: including Medicaid expansion in her 2023 state budget and proposing expansion legislation with a work referral component. Neither were included or acted upon, however, by the state’s Republican-controlled legislature before it adjourned.
Both of North Carolina’s legislative bodies passed bills—the Senate for Medicaid expansion tied to work requirements and the House to establish a committee to study expansion. The 2022 session adjourned, however, with no further advancement.
Medicaid expansion under constitutional amendment will be on South Dakota’s ballot in November 2022. If approved, expansion would begin July 2023 and would not include added restrictions for the newly eligible.
Among the 39 programs that have already expanded Medicaid (38 states plus the District of Columbia), one state— Missouri— sought to add work requirements and make expansion subject to annual funding. The bill passed by the state House, however, did not advance during the session.