Payer executives are focused on improving member experience and engagement, implementing value-based models and controlling rising costs in the second half of 2024.
The 15 leaders featured in this article, part of an ongoing series, are speaking at upcoming Becker's Payer Issues Roundtable events. The fall roundtable will take place Nov. 4-6 at the Swissotel in Chicago. The spring roundtable will take place April 28-29 at the Hyatt Regency in Chicago.
If you work at a health plan and would like to join as a speaker in April, please contact Randi Haseman at rhaseman@beckershealthcare.com.
Note: Responses have been lightly edited for length and clarity.
Question: What is your No. 1 focus for the second half of 2024?
Value-based models
Anthony Thompson. Senior Vice President of Healthcare Network Strategy at Capital District Physicians Health Plan (Albany, N.Y.): I am proud and excited to say that CDPHP has started off the year strong with the creation, and continuation, of strategic relationships being the cornerstone of our strategy. In the second half of 2024, my team will be laser-focused on aligning providers with value-based care models that foster collaborative partnerships with an effort to further improve patient care coordination and member experience. Additionally, as we further align in our affiliation with the Lifetime Health Companies, we will take a closer look at optimizing contracting processes to ensure timely and transparent communication with our provider partners. Lastly, as technology advances, we will leverage data analytics and machine learning to identify performance improvements that would allow us to better structure our long-term relationships with providers, keeping with our mission of being a member-centric and physician-focused health plan.
Jeremy Wigginton, MD. Chief Medical Officer of Capital Blue Cross (Harrisburg, Pa.): As we enter the second half of 2024, my primary focus will be on driving healthcare value in the market. Value is defined differently across stakeholders but hinges on access to high-quality, affordable healthcare. Through a number of initiatives, I will be working on bringing better solutions and a better understanding of this direction to our providers, business leaders and members. A key clinical area of my attention will be on cardiovascular care and holistic cardiovascular risk reduction through member-centered approaches.
Member experience and engagement
Tina Bandekar. Director of Pharmacy Programs at Massachusetts Behavioral Health Partnership (Boston): From my perspective, the healthcare industry is at the cusp of technological transformation. Some of the inherent issues in the industry have been access to quality care, cost control and staff retention, which have plagued the industry for years and have always been a priority for many healthcare leaders. With the recent advances in machine learning and artificial intelligence, there appears to be some light at the end of the tunnel.
1. Expanding access: We are seeing a lot of telehealth integration into provider offerings, not only primary care, but also specialty consults like mental health services and chronic disease management. Teladoc is a great example of a company that is expanding its virtual care offerings. Kaiser Permanente has also successfully incorporated virtual care in its care delivery model.
2. Cost management: Another area of focus for many healthcare organizations is adoption of value-based care, where there are some risk sharing agreements or pay-for-performance contracts. The goal is not only to achieve cost savings but also improve patient outcomes. Using care management to help patients navigate care or getting them in touch with the available resources has shown tremendous cost benefits for patients and in addition to many healthcare organizations.
3. Staff and resource management: To improve quality of work and reduce administrative burden on the healthcare staff, leveraging AI and ML for things such as improving administrative efficiency and clinical decision support is a growing focus. Utilizing predictive analytics to make better clinical decisions or predict trends and manage disease spread can help with population health management. Utilizing technology may not only personalize medicine for the patients, but also prevent and or reduce human errors. Additionally, AI can be used for onboarding and training new team members, or build better staffing models based on historical volumes that may help alleviate some of the staff burden and prevent staff burnouts.
Overall, the focus areas for 2024 in the healthcare industry continue to demonstrate the ongoing transformation of the industry driven by technological advancements, policy shifts and a greater emphasis on patient centered care and positive outcomes.
Jack Hooper. CEO and Co-Founder of Take Command Health (Richardson, Texas): Our top focus for the second half of 2024 is working with carrier partners to smooth out the open enrollment process for ICHRA enrollees. Currently, the ICHRA experience for employees is pretty rough. Carriers are starting to realize the opportunity to create and design plans unique to the ICHRA audience and implement service and support procedures to better serve ICHRA clients. We are excited to work with these carriers to polish the employee experience and demonstrate how well ICHRA can run.
Joanne Mizell. COO of Banner|Aetna (Phoenix): During the second half of the year, I'm focused on the build and launch of our latest initiatives to enhance member onboarding. Our updated process is designed to help new members identify any possible gaps in their provider access or prescription drug coverage. For most people, there is no disruption. But if there is a change, we assist them — proactively — in finding new providers or addressing the Rx coverage. Our goal is to take the anxiety out of switching health plans and make the transition to Banner|Aetna a smooth and welcoming one.
Harlon Pickett. President of Eagle Care Health Solutions (Austin, Texas): Our number one focus for the second half of 2024 is member engagement, particularly highlighting the benefits of primary care. We believe that a strong foundation in primary care is essential for improving overall health outcomes, reducing healthcare costs and enhancing the quality of life for our members. By actively engaging our members, we aim to foster a deeper connection between patients and their primary care providers, which is critical for preventive care, early diagnosis and the effective management of chronic conditions. This leads to better health outcomes and reduces the need for costly emergency room visits and hospitalizations. By prioritizing member engagement, we ensure that our members are informed, supported and motivated to participate actively in their healthcare journey, ultimately leading to a healthier, more resilient community.
Shelley Turk. Divisional Senior Vice President of Illinois Health Care Delivery at Health Care Service Corp. (Chicago): We have a lot to accomplish in the second half of 2024 and my number one focus is ensuring that we meet the needs of our members, employer groups and providers to the best of our ability. Part of that is ensuring that the systems that power the plan are optimally healthy. We performed an end-to-end review of our operations, contracting and finance areas at the end of 2023 and, among other things, ensured that one of our key reimbursem*nt systems was healthy and could handle additional networks and customization. We also replaced a critical server that we knew was close to the end of its lifespan. That work led to a new initiative for 2024 to ensure that all applications, systems and software that we use every day are also healthy, maintained properly, and have the right upgrades, fixes and patches timely. If we can't run our core business properly, everything else grinds to a halt, so it will be important in the second half of 2024 to keep a strong focus on ensuring that our technological foundation remains solid.
Shawn Shuman, MSN, RN. Director of Medical Management at Peak Health (Morgantown, W.Va.): My number one focus for the second half of 2024 is to continue to find operational efficiency to respond to our members' needs while ensuring care is available in the right setting, at the right time, in the most cost-effective way possible. Being able to anticipate the needs of our members with a focus on prevention, wellness and education is our goal. One of our main priorities is to infuse concierge care management to best meet the members' needs based on how they want to engage by using multiple modalities and strategies to provide the best-in-class care management and interventions.
Health outcomes and equity
Abdou Bah. Senior Vice President of Medical Management and Chief Health Equity Officer of EmblemHealth (New York City): Improving the health status of our members shapes our work every day at EmblemHealth. We are making it easier for our members to get the care they need when and where they need it. We are doing this through projects focused on managing chronic conditions, opening more of our Neighborhood Care centers where in-person assistance is provided, streamlining processes, introducing new services and automation, encouraging portal adoption and more. We have several active initiatives involving members and providers to elevate and streamline their experience working with us. All of this is centered around our focus on maximizing performance around quality measures to close gaps in care and improve our members' health outcomes. We are also preparing for 2025, including the implementation of the Medicare Prescription Payment Plan.
Joe Glinka. Director of HealthChoices at Highmark Wholecare (Pittsburgh): A key area of emphasis for Highmark in the second half of 2024 is expanding our reach and positive impact on the lives of beneficiaries served by government sponsored healthcare programs.
We have this opportunity across our entire government program footprint beginning with our Medicaid entry into West Virginia later this summer, which builds upon our 80-year history of caring for West Virginians. Highmark also has a long history in the state of Delaware, including in the Medicaid space. In 2025, we'll expand our reach in the state by caring for dually eligible individuals served by Medicare Advantage for the first time.
Within our largest service area, Pennsylvania, we're currently sharing timely and relevant data with the commonwealth's Department of Human Services to ensure appropriate managed care organization funding levels for 2025. Appropriate funding is essential to cost-effectively impact member health outcomes and overall health status, helping members lead their best lives through improved health.
Kelli Tice, MD. Chief Health Equity Officer and Vice President of Medical Affairs at GuideWelland Florida Blue (Jacksonville): At GuideWell, advancing health equity and ensuring that every individual has an equal opportunity to attain their highest level of health is a top priority.
Our number one focus for the remainder of 2024 is health equity enablement. As the work of health equity continues to gain momentum, we will maintain intense focus on creating a robust health equity infrastructure.
We have expanded the health equity training offered to our teams to strengthen the foundation upon which our health equity strategy sits.
We have developed tools for our teams to use in strategy development, initiative design, vendor selection and analytics, and we will focus on broad deployment of these tools for the remainder of the year.
Our work in maternal health equity, chronic disease and data collection continues, but as the industry races toward AI and digital solutions, we place great value on the proper stewardship those solutions require — and this is rooted in the fundamentals of health equity.
Care coordination
Stephen Anderson. Vice President of Provider Contracting and Network Administration at Blue Cross Blue Shield of Michigan (Detroit): Our focus for the second half of 2024 is working with our physician partners to support our members to the right level of service for their ongoing needs. As we've all seen since last year, utilization continues to increase. By partnering with physicians, we can assist members to improve their health while managing finite resources through the rest of the year.
Pankaj Gupta, MD. National Medicare Advantage Medical Director for Clinical Performance at Optum (Eden Prairie, Minn.): The focus for the second half of 2024 is readmissions.
As a Medicare Advantage program, coordination of care is key.
Readmission rates are one method for assessing the role that managed care can play in improving quality and value. Recognizing the role of readmissions in improving the value and quality of healthcare systems, since 2013 CMS has penalized acute care hospitals with relatively high readmission rates under the Hospital Readmissions Reduction Program. Moreover, accountable care organizations are now being evaluated using all-cause readmissions. Although it may be impossible to target a specific readmission rate that could be considered appropriate or acceptable, MA plans have the potential to provide post-acute care that is more coordinated than for those covered through traditional Medicare. Thus, it is plausible that MA plans can improve so-called "care transitions," which have been shown to reduce readmission rates.
Ria Paul, MD. Chief Medical Officer of Santa Clara Family Health Plan (San Jose, Calif.): As we are midyear of a relatively COVID-less year, and we have already seen the surge of various procedures like colonoscopies, knee surgeries as a result of the pent-up demand post-COVID, now our priority is focusing on engagement of patients to ensure health and wellness. At this time, emphasis on various preventative screenings, involvement of patients in clinical programs; like [diabetes, hypertension, chronic kidney disease], integrated behavioral health, wellness programs — exercise, nutrition — will help patients stay healthy and out of acute care settings. Awareness of the performance status of various quality, utilization metrics, midyear and implementing work plans to monitor/track/meet these metrics will continue to be a major strategy for the second half of the year. All of these efforts are geared to improving the health of our patients and ensuring the viability of various value based programs.
Bruce Rogen, MD. Chief Medical Officer of Cleveland Clinic Employee Health Plan: As a payer, our current number one focus is maintaining viability of the plan in the face of GLP-1 pharmaceuticals for weight loss given demand and volume and cost.
