By Elizabeth Bigham
When healthcare executives discuss preparing for surges, it’s generally understood that they are not talking about seeing hospitals and health systems overwhelmed by patients with COVID-19.
But there is another type of surge waiting in the wings that healthcare organizations need to start preparing for now – the one that will result once the pandemic has passed and attention reverts back to elective procedures and chronic conditions.
Individuals who have been waiting anxiously for knee replacements, back pain treatment and other “non-essential” conditions will want to see their physicians and surgeons as quickly as possible, creating a spike in demand, followed by claims and payment. Those who have let their chronic conditions go unmanaged will need to be re-engaged to close their care gaps before the health and financial consequences become too great.
Managing this sudden surge could easily overwhelm healthcare organizations still relying on manual review and utilization management systems. It will also be easy for individuals with chronic conditions but no immediate care needs to slip through the cracks, particularly as healthcare organizations struggle to get back to whatever “normal” turns out to be.
Fortunately, there are technologies that can be implemented relatively quickly to help address these and other issues. Some areas healthcare organizations may want to consider include:
- Advanced predictive and prescriptive analytics to help find the members who not only have the greatest need for care for their chronic conditions but are also the most willing and able to follow a plan of care to improve outcomes. This will be particularly important in the months immediately following the worst of the COVID-19 pandemic, when hospital, health system and health plan resources are exhausted and working to recover. Analytics can help them prioritize those resources to where they will have the greatest impact without further stressing the entire health system.
- Data and analytics to help determine where efficiency opportunities exist. For example, health plans may want to focus on Utilization Management to determine whether programs are focused on the right pre-authorizations or whether some providers can qualify for gold-card status. By streamlining authorization lists and ensuring resources are focused on reviewing high-value services and those most costly to the organization, health plans can create significant shifts in productivity and medical cost impacts. The result is better health outcomes with greater efficiency while reducing costs – three elements that will be greatly needed in the post-pandemic world.
- Automation technology to streamline workflows. A medical management system embedded with the right analytics can help healthcare organizations move faster with fewer people, even in the face of a sudden influx of patients. These analytics should help healthcare organizations automate manual processes and create more intelligent operations. They should also offer transparency and collaboration across key stakeholders and care management programs while creating smarter methods for member as well as provider engagement and outreach. These systems must also incorporate the flexibility to meet unique organizational needs while ensuring compliance is maintained.
- Advanced digital technologies to eliminate labor-intensive operations. Technologies such as natural language processing (NLP), artificial intelligence (AI), machine learning (ML) and robotic process automation (RPA) further streamline operations by simplifying processes and tasks while eliminating the need for certain manual interventions entirely. One simple example is the use of automation for clinical intake. Rather than having a live agent manually process a fax request, automation can be used to fetch the information required to create a new request and assign it to a clinical reviewer. An automation solution that uses NLP, ML and RPA can search through multiple systems to find and serve only the data a clinical reviewer needs to make a determination so the bulk of the reviewer’s time can be spent on making decisions rather than searching for information.
The longer the pandemic continues, the more the demand for post-pandemic care grows. The right technologies can deliver the efficiencies needed to equip your organization to tackle the upcoming surge in demand and medical costs.
Elizabeth Bigham is the Senior Vice President and General Manager over EXL’s Clinical Services business. Elizabeth has more than 25 years’ experience in domestic and international healthcare markets, including holding senior executive positions in care management and operations within health plans as well as a serving as a partner at a top national consulting firm.