Healthcare Trends
  • Healthcare Trends

The Future of Health Plans

The health insurance market is expected to shift significantly over the
next decade. Avalere works with health plans to chart a course forward.
Overview

Navigating Through a Changing Landscape

The policy and regulatory landscape that health plans operate in is changing rapidly. Developments such as Medicare Part D redesign, changes to the Medicaid quality rating system, new therapies such as GLP-1s, and evolving technologies like artificial intelligence, will continue to evolve how plans operate and deliver care. Plans cannot wait for the dust to settle on these changes. They should be preparing for tomorrow’s changes to the healthcare market today. ​

Avalere helps health plans analyze the changing market to inform strategic decision making. We support end-to-end strategy—from ideation to implementation—business process optimization, and compliance reviews to help set plans up for success. ​

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Trusted Partnership

Amidst changing regulatory, technology, and market dynamics, health plans partner with Avalere to ensure their strategy and operations are aligned to achieve long-term goals.​

Video

AI for Health Plans and the Future of Clinical Data​

In a three-part video series, Avalere and partners explore how plans can employ artificial intelligence to optimize clinical data management. In the first video, we discuss the regulatory and market dynamics around clinical data and implications for health plans; the second video explores how plans are operationalizing enterprise clinical data; and the third video details real-world examples of how AI can streamline data management and support plans’ decision making.​

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Case Studies

How We Have Helped Clients

Including Patients with ESRD in Medicare Advantage Plans

The 21st Century Cures Act allowed Medicare beneficiaries with end-stage renal disease (ESRD) to enroll in Medicare Advantage (MA), requiring MA plans to adapt to this clinically complex patient population with high care needs. The client, a large MA organization, sought our assistance to learn more about the characteristics and enrollment patterns of patients with ESRD enrolled in fee-for-service (FFS) Medicare in its market. The client used the recommendations resulting from our data analysis to adjust its strategy, tools, and benefits to accommodate this beneficiary population.

Ensuring Accurate Risk Score Payments to a Mid-Sized Health Plan

A regional health plan engaged us to (1) evaluate its risk adjustment processes for program compliance and identify improvement opportunities, and (2) assess the completeness of its data submissions to the Centers for Medicare & Medicaid Services (CMS) for use in risk adjustment calculations. In part one, we identified deficiencies in the client’s process that resulted in omitted data from providers and supplemental sources, with a potential risk score and revenue impact of $90 million. In part two, we analyzed the client’s claims data inputs and outputs. We identified several eligible claim sets that had been omitted from submissions to CMS, resulting in artificially low risk scores with a potential revenue impact of $20 million over two years.

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AI for Health Plans: AI and Clinical Data in Action

In the third and final installment of our AI for health plans video series, Avalere is joined by experts Mia Bolton and Teddy Gedamu from Tenasol to share real-world examples of how artificial intelligence (AI) can streamline data management and improve decision-making in health plans.

  • Eric Levine
  • Michael Lutz
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