Xerox Care Integration Services (XCIS), a division of Xerox Healthcare, provides health insurers, providers, and employers with personalized member and provider outreach and communications. XCIS is focused on creating a connected healthcare ecosystem – one that creates a prospective, personal, and guided journey for each individual. XCIS utilizes data analytics and rules-engine-driven automation, along with a front end of professionally staffed call centers, to do outreach to help individuals understand their health risks and needs. Since the passage of the ACA, XCIS has been supporting health plans with their public exchange products.
Here, Jason Grau, Senior Vice President, Population Health Strategy and Enterprise Analytics at XCIS, shares his observations of population trends in the ACA population, and he discusses why and how it can be challenging to engage the ACA population pool.
How is the ACA population similar/different from the Medicaid population?
How is it similar/different from the Commercial population?
The ACA population bares resemblance to the Medicaid population in that both have members with complex needs. For example, like the Medicaid population, some sub-segments of the ACA population are low-income and face significant barriers to care, such as a lack of childcare services or transportation.
Meanwhile, compared with the Commercial population, newly covered members – some of whom gained insurance for the first time through the ACA – tend to be less knowledgeable about how to utilize their benefits and navigate the healthcare system.
In addition, the new members that came into the ACA market were sicker and the prevalence of chronic health conditions was much higher than the average Commercial member. This is in contrast to the pre-ACA individual insurance market, which as a whole was typically much healthier than the employer-sponsored group market.
However, it is important to note that while some generalizations about the ACA population can be made, the profile of the ACA population continues to evolve; and the reality is the population is actually composed of distinct sub-populations – some young and healthy, some low-income, some polychronic.
All of the unique differences of these sub-populations bring into clearer focus the need to engage members in a much more personalized and guided manner. The one-size-fits-all approach that many payers have used to serve the Commercial population will not cut it.
As you point out, the ACA population is quite diverse. What’s the key to effectively engaging members with such different needs, understanding, and utilization?
Payers and providers operate with the best of intentions to target programs and outreach to members; but what usually happens is the members with the most significant needs get bombarded with multiple messages. This creates confusion and member abrasion; and, more often than not, the messages get tuned out.
To combat this, we need to establish a personal healthcare itinerary for each individual at the outset. Such an itinerary should include not only a person’s clinical profile, but also their behavior profile, motivations, preferences, and social factors that may present barriers to care. The itinerary can then inform how payers and the healthcare team prospectively manage and guide the consumer on their healthcare journey.
Honestly, I think much of the innovation to create a consumer-centric healthcare model is going to be driven outside of the Commercial population, particularly in the ACA. The type of engagement and education that is needed for the ACA population requires more intelligent and rigorous solutions than we see available in the Commercial population, where most programs are fairly cookie cutter in design.
The one-size-fits-all approach that many payers have used to serve the Commercial population will not cut it.
Many payers are struggling to manage their ACA lines of business. What do you think is the key to succeeding with this member segment?
To succeed in the ACA line of business, it is critical to have a good sense of the overall risk in the market. Risk adjustment can sway top line revenue of this block of business by more than 20 percent – that’s plus or minus 20 percent in an environment that earns only 3 or 4 percent in good times – so an effective risk adjustment ground game is imperative.
But the exchange population layers in wrinkles that create challenges around managing risk. For insurers, you have a lot of members who are brand new to you. You don’t know what they look like or what their health risks are until after the fact. And it’s typically a population that churns pretty quickly.
So to succeed in this market, you have to start engaging them on day one; and you have to do it prospectively, not reactively. For example, a number of these people don’t understand how to utilize their benefits. We have programs that are targeted at onboarding and activating new exchange members. We go through and do a very rich and very personal health history to understand their needs and preferences. We also fill in an understanding of personal factors that may result in barriers to care.
When we on-board a member, we might learn someone has a need for childcare services in order to make it to a doctor appoint. Many people have irregular schedules and may need transportation assistance. Addressing and resolving those barriers to care is absolutely essential to keeping that person on their path.
What is the key to scaling this sort of approach?
The trick to realizing scale is to leverage assets that are already in place. However, most of those assets need to be pivoted to align with a business model that rewards a focus on prospectively managing the healthcare, quality, and experience of the member. It requires a change in mindset for how to adapt and deploy existing capabilities. The biggest hurdles to this are culture. The approach and mentality that most executives have is you have to rip out entire systems and replace them with new ones. [Today’s innovation] requires more of a start-up mentality. That is, quickly figure out how to augment what’s already in place, rather than replace.