COVID-19: How Can Payers Prepare for Mandates and Support Pandemic Relief Efforts

Elizabeth Bierbower, Former President of Humana’s Group & Specialty Division

Healthcare can achieve optimum efficiency when patients are at the center of care. When patients have the necessary information to navigate their care journey, they will choose the path to high-quality care at the lowest costs. Cost-sharing and insurance premiums are rising consistently since the last decade for employer plans, which covers nearly half of the country’s population. Plan members are shouldering a part of the healthcare cost burden, so they want to keep it as low as possible. At the same time, they want maximum value for their money with access to quality care.

CMS identified this as an opportunity and issued the Final Interoperability and Patient Access rule. The rule allows patients to access electronic health data through any third-party application of their choice. The rule intends to allow patients to take control of their data and determine who can see which data. It will also make transferring data from provider to provider easier. So that patients can be ensured that their provider is fully aware of their medical history. 

The Challenge of Providing Members Access to Healthcare Data 

The biggest challenge that health plans will face is to extract data from multiple sources in-house, clean and scrub it, and ensure it is in the appropriate format as required by the Centers for Medicare and Medicaid Services (CMS). Some health plans have been in business for a really long time. Patient data has been accumulating through these years in legacy systems. Providing access to that data through certified third-party applications will require a lot of effort on the part of health plans. The health plans also have to ensure tight authentication standards so that only the people requested by the members have access to their healthcare data. 

In addition, there are multiple problems associated with provider data. Incorrect data in the provider database costs close to $3 billion annually. CMS has also issued warnings for inaccurate provider directories, high claim-reprocessing volumes, and substantial encounter-data rejection rates. Payers have been addressing the data issues with short term solutions. But now they have to resolve the provider data problems for good and make health data readily available to the members.

The COVID Crisis Upended The Payer Compliance Initiatives

Payers are in solidarity with providers and patients in this time of crisis. While providers work tirelessly to help an increased number of patients access the required care, payers are providing support through fast track reimbursements and reduced utilization management.

 Many health plans are focused on ensuring that their members have access to resources to fight COVID, which is why CMS extended the deadline for the Final Interoperability rule. Utilization patterns are witnessing a significant change. Many members are not receiving scheduled care as some elective surgeries are rescheduled and some provider offices are shut down. There has been a drop in certain kinds of utilization. Conversely, there has been a dramatic surge in telehealth office visits and behavioral health services.

The Road Ahead for Health Plans

Healthcare payers have endured significant claims-based, economic, and operational challenges during the pandemic. While they battle those bottlenecks, they also have to ascertain and prepare for the future and devise ways to ensure that their members have access to quality care.

Health plans will have to try to anticipate what utilization patterns will look like in the future, especially in the next year. Telehealth utilization will not be the same as it was pre-COVID. They will also have to ensure that members have access to care. They will have to reach out to members, especially those who are the most vulnerable. They will have to make sure members are not suffering from social isolation, they are taking their medication and they have access to transportation to get to the doctor.

Provider Alliance for CMS Compliance

CMS is handing over the reins of the care journey to the patients to improve care delivery through the Interoperability rule. Providers will play a key role in enabling access to healthcare data to patients by streamlining data and closing coding gaps. Payers must assist providers with their data needs to ensure compliance with the CMS rules.

As the pandemic ends and CMS comes out with more definitive long term rules and coverages, it is going to be important to ensure that providers are on the same page with payers. Health plans can partner with providers to educate them about the acceptable telehealth codes and what type of services are to be performed using those codes. Providers want to take care of their patients and they want to do it well. They want to leverage technology to ensure patient access to care and ensure their safety, especially for patients who suffer from multiple comorbidities.


About Elizabeth Bierbower

Elizabeth Bierbower is a strategic leader with more than thirty years of executive experience in the health insurance industry. She has experience scaling cost-effective and profitable growth strategies through internal innovation, and a reputation as being one of the industry’s most fiscally responsible and progressive leaders. Bierbower currently serves on the Boards of Iora Health, the American Telemedicine Association, and is on Innovaccer’s Strategic Advisory.

Previously Beth was a member of Humana’s Executive Management Team and held various roles including Segment President, Group and Specialty Benefits, and was an Enterprise Vice President leading Humana’s Product Development and Innovation teams.


Addressing Social Determinants of Health: IT Solutions to Engage Community Resources

Addressing Social Determinants of Health: IT Solutions to Engage Community Resources

What You Should Know:

– The latest report from Chilmark Research examines the
new approaches and tools for utilizing community resources that can address
social determinants of health, giving providers the ability to extend care
beyond the confines of the clinic.

– This research indicates that the next two years will largely bring an expansion of product capabilities with slow and steady growth in implementation as the market better defines key variables and sets standards for performance.


COVID-19 has dramatically increased the overall population’s need for community resource engagement in traditional healthcare settings. The steady march to value-based care (VBC) continually amplifies interest in solutions that contribute to utilization management strategies. Vendors are rising to meet this need by connecting community-based organizations to various healthcare partners so that both may benefit from the coordination of service provision. 

The latest Chilmark Research report, Addressing SDoH: IT Solutions to Engage Community Resources, evaluates these solutions, identifying the strengths and weaknesses of options in the market and predicting how the market will develop in the future. Research in this report is based on interviews with executive leadership teams of solutions vendors, executives from the major EHR companies, and extensive secondary research. 

Vendors discussed in the report include aunt bertha, Cerner, Epic, HealthEC, Healthify, NowPow, Signify Health, Solera, Unite US, Xealth

Leveraging Community Partners Is Key
to Addressing SDoH

Community partners
are some of the best resources providers can
utilize to address the social factors impacting patients’ health status, but
this is a new need for HCOs, which under fee-for-service (FFS) tried to keep
all care within the clinic to maximize revenues. Data management and liquidity
make effective integration with external partners a key barrier to
implementation, while legal and internal engagement issues continue to slow
adoption.

Predicted 10-Year SDoH Adoption Trajectory

This research indicates that the next two years will largely bring an expansion of product capabilities with slow and steady growth in implementation as the market better defines key variables and sets standards for performance. Within five years, a public option for insurance will dramatically increase the rate of solutions adoption, culminating in >80% adoption in provider locations by 2030.

The report provides a roadmap and
predicts key inflection points for the greater adoption of these solutions, and which social determinants have historically been
the best predictors of increased health services utilization. It includes brief
profiles of key vendors providing this functionality, and how they plan to
impact community health.  

“This has been a major challenge to healthcare systems, and people now get that we need to address [SDoH] better. The pandemic has proven to be an additional, critical driver for continued expansion of VBC, which requires understanding all of the factors that can influence a member’s health status,” according to report co-author Jody Ranck. “We see an opportunity here from the pandemic, that it has basically shown us where the failures are in the system today, and that going forward we need to do more to engage resources beyond the clinic.”