Unlock the Power of Predictive and Actionable Analytics to Improve Business Outcomes

CG Adams: Hello, everyone. Welcome to the Payer Principle, a Salesforce healthcare podcast created exclusively for payers. I'm your host, CG Adams. On the show, you'll hear insights from healthcare industry experts and trailblazer organizations on all things payers such as trends, business challenges, and the latest technological solutions. Today's episode focuses on analytics and how payers can leverage predictive analytics to improve both business and number outcomes. I'm joined today by Dr. Barry Chaiken. Dr. Chaiken is currently the clinical lead at Tableau, a Salesforce company with over 20 years of public health and healthcare industry expertise. Dr. Chaiken, welcome to the podcast. It's great to have you on today.

Dr. Barry Chaiken: Thanks for having me. I really appreciate it.

CG Adams: So understanding that the world is in unprecedented times, what are some of the key business shifts payers are seeing in response to the COVID- 19 pandemic?

Dr. Barry Chaiken: Well, the first thing I want to say about that is that we have a long road ahead of us. It's not just a couple of weeks or months, it may be a year or two years, even with a vaccine and treatment, so let's set that as a foundation for our discussion today. The reality for payer organizations is they've seen a dramatic shift in covered lives. Frankly, they don't really know who their customers are, who their covered lives are. There are so many people who've been unemployed, over 40 million people around the United States, which means about 20% of them are no longer covered by group health, which means, for these organizations, payer organizations who had planned to have a particular type of covered lives that they had to take care of and pay the insurance for, all of a sudden that whole mix has changed both in age and sex and industries, et cetera. They also have no idea what the future holds for them. Will there be increased employment and there'll be an increase in group health or will there'll be a decrease in group health? So tremendous shift, tremendous upheaval for payer organizations. Also, there's been a change in the medical loss ratio for them. For example, without a pandemic, without COVID- 19, they would expect to have a certain number of knee replacements, or hip replacements, or injuries, or various types of chronic disease happen over the period of the year, how would they know that? Well, they look back at the history of the last couple of years, their actuaries get together and they figure out," Okay, this is how much money we have to put aside in a pot that'll pay for the care of those patients." Well, everything's been turned upside down. They no longer know who those covered lives are, so they clearly don't know what their medical loss ratio is going to be, how much money they have to set aside to pay for care. Additionally, and this is very important to payers, additionally, we know that the federal government said that they would pay for COVID- 19 care, but as we all know, there has been a shortage of testing and additionally, some of the tests are not really accurate. If a patient does not have a COVID 19 test, they clearly don't have a COVID- 19 diagnosis. They don't have a COVID- 19 diagnosis, then the government doesn't pay for their care, reimbursing the hospital instead of having the payer reimbursed. So there's all this unknown. The things that payer organizations really dislike is unknown, the inability to prepare. Insurance companies need some level of preparing and they base that upon the past. Their actuarials do the analysis and they base it on the past, and that obviously is a real, real challenge for payer organizations. So right now, they need to go ahead and redo those actuarial tables and instead of them doing on a yearly basis, they have to go and do their planning pretty much on a monthly basis, or even shorter than that, to be able to make sure that they have the money in the bank to pay for care, to understand what they're going to do next year relevant to their premiums. Their planning is incredibly valuable now.

CG Adams: Well, how would you go about preparing and planning given the situation?

Dr. Barry Chaiken: You have to do planning through analytics, you have to do planning through statistical analysis, you have to do planning for that modeling, and payer organizations are knee- deep in doing that type of work right now due to the impact and changes in the unknown delivered by COVID-19.

CG Adams: Dr. Chaiken, you've just unpacked a lot from the shift in covered lives to medical loss ratio, to shifts in the member payer mix, what about telehealth and virtual care considerations? Because I know that this is also another huge business shift that payers are facing during this time.

Dr. Barry Chaiken: Telehealth is incredibly valuable during a pandemic, but frankly, telehealth is very valuable even without a pandemic. There's been a tremendous shift from what telehealth used to be, which was a benefit provided, often to group health beneficiaries, where you'd be able to get some medical advice through a telemedicine type of visit. The challenge for telemedicine pre- COVID was the fact that CMS, the federal government, states who Medicaid and additionally, payer organizations, insurance organizations did not pay for telemedicine visits. And if they did, it was a very small amount of money. So therefore, provider organizations are incented to have patients come into the hospital, into the clinic, into the physician's office and not really do these virtual visits or telemedicine visits.

CG Adams: So what's changed about this dynamic with the onset of the pandemic?

Dr. Barry Chaiken: Due to the pandemic and the national emergency declared by the federal government, CMS said," We are going to now pay for telemedicine visits." Why did they do that? Because they felt that keeping, particularly the elderly out of hospitals and out of clinics, particularly the time during the shutdown back in March and April, it protected those people from having to go into an environment where they potentially can contact the virus. But additionally, they wanted to remove the burden from the hospitals and the clinics where people were being mobilized to take care of COVID-19 patients. So CMS said," We'll pay for telemedicine visits. And on top of it, we will pay the same amount as if you had an in- person visit." Payer organizations, to their credit, followed along and said," We will do the same thing." By changing the reimbursement, the number of telemedicine visits in some of the organizations that I've spoken to in the last couple of weeks and months has been not 100%, but 3000% or 5000% increase, 50 times or more numbers of telemedicine visits. Provider organizations had to scramble to be able to provide that.

CG Adams: Altering the reimbursement model has clearly led to a huge surge in telehealth or virtual visits that payers now have to account for, what's the inherent challenge there?

Dr. Barry Chaiken: The challenge they have is to say," Are we going to continue to pay for these telemedicine visits once the federal government decides that the national emergency is over and maybe CMS decides to pull back from paying for telemedicine visits? What's the value to us to pay for medicine visits versus in- person visits? And how do we go ahead and figure out what our medical loss ratio is going to be? How do we set our premiums?" They have to do a tremendous amount of analytics along those lines to figure out how they're supposed to prepare for these telemedicine visits. And frankly, if we accept the fact that the pandemic is going to go on for a year or longer, or at least people are going to be reluctant to go into medical facilities for a period of time, payer organizations have to figure out what are they're going to do with those patients. They clearly want them to be managed well through their chronic diseases, and if that means having to pay for telemedicine visits to make that happen, they're probably going to think clearly to go in that place.

CG Adams: Recent analysis from Frost& Sullivan actually predicts that demand in telehealth will increase 64% in this year alone in direct response to the pandemic. So how are you seeing payers use analytics specifically to access not only the acceleration, but also the adoption of telehealth considering the staggering growth that we're seeing with it right now?

Dr. Barry Chaiken: The reason why analytics is so incredibly important to payers right now is they have no history of what is going to happen for the rest of this year and in 2021 and 2022. They have no idea. The only way they can even guess and model what's going to happen going forward is for them to actually look at what is happening in each of the stage, in each of the regions, in different types of diseases amongst patients to be able to get an idea of what may happen next year and the year after so they construct to understand how they can prepare for it. Until they do that analysis, they're really going by gut, and gut isn't going to cut it when it comes to setting premiums and preparing for the future, particularly in the next year or two with this pandemic.

CG Adams: Well, it's definitely easy to see why telehealth has to be at the forefront of payer strategies when it comes to member engagement and offering virtual care services. Additionally, it really has the capacity to help payers in combating social barriers to healthcare such as access to care or health literacy, barriers that have really truly been exacerbated by the pandemic. So I agree with you, this expansion of care virtually is definitely something that payers need to get a grip on and really incorporate into their ongoing strategies looking to the horizon. I want to pivot for a moment and discuss at risk or high risk member populations, because according to the CDC, older adults and those with underlying health conditions are at a greater risk of severe illness from COVID- 19. Dr. Chaiken, how are you seeing payers use analytics to identify high risk populations during this time and help these members to better manage their conditions proactively?

Dr. Barry Chaiken: Well, clearly the elderly are a great risk for COVID- 19, but as we also know, various types of ethnic groups are at risk, particularly African- Americans and Latinos here in the US. There's a great need to protect these populations, not only from the virus, but also from other chronic diseases because we also do see higher incidents of chronic diseases such as diabetes and hypertension, cardiovascular disease in these types of populations. And from a moral perspective and from a financial perspective, we need to make the effort to protect these populations so that they can continue to contribute to society and as well as have a long and healthy and fruitful life. So we've done a lot of work, or I should say payer organizations have done a lot of work addressing population health. The thing that's changed this a little bit and made it a bit more of a crisis is the idea that because of COVID- 19 they have these vulnerable populations. So payer organizations are using analytics to be able to understand better, not only who has these chronic diseases, but also to understand, based upon ethnicity and region of the country they live in, what other risk factors, social determinants of health are risk factors associated with their chronic disease. And then they need to make planning around their population health initiatives to protect these populations, the elderly and other vulnerable populations, because of COVID- 19. I would imagine that these organizations, these payer organizations, through their analytical work at looking at these populations, will go ahead and will dramatically change how they do population health going forward because COVID- 19 has forced them to not only focus on the elderly, but focus on these other subgroups that are at risk. I think, and I'm hopeful that their analytical work will make a big difference in terms of how they put together their programs to help these populations. It's a pretty interesting time because of COVID- 19. Around population health, one other factor I wanted to share with you is that there's been a tremendous disruption of population healthcare delivery, essentially, because people haven't gone into the hospital or to the clinic or seen their doctor because people are afraid or they weren't able to go in in the first place. Maybe they need to have an in- person visit instead of a telemedicine visit, so this disruption of care has upended population health work. But I think through analytics, the payer organizations are able to understand where they have fallen short in the last couple of months because of COVID- 19 and the initiatives they have to take going forward to try to catch up and take care of these populations.

CG Adams: Another population of members that are top of mind for payers are the 64.1 million Medicaid beneficiaries that exist today. To date, 2. 8 million individuals are without health insurance coverage due to loss of employment as a direct result of the economic downturn brought on by coronavirus, and we have twice that amount of newly enrolled Medicaid beneficiaries in states without Medicaid expansion. So what does that ultimately mean for Medicaid plans and how these members are being affected?

Dr. Barry Chaiken: The pandemic has had a tremendous impact on states and their Medicaid plans. Medicaid makes up, in most states, the majority of the state budget. And as people fall off of group insurance, there's only three places they can go, they can have no insurance at all, they can go ahead and go on a family member or a spouse's plan, or they can qualify for Medicaid. inaudible there's a fourth one, they could also purchase their insurance on their own. A large number of people are unable to purchase their own insurance and are going to be protected by Medicaid. In those states that had Medicaid expansion, there is a tremendous ability to get on Medicaid and be covered so they can get care. In states that did not have Medicaid expansion under the affordable CARE Act, there's less of a chance that those people who fall off of insurance will be able to get on Medicaid. So the reality is for most states, and it varies based upon whether they had expansion or not, there's been a tremendous increase in patients who are covered by Medicaid.

CG Adams: What does this mean for payers who offer Medicaid plans?

Dr. Barry Chaiken: For payer organizations who are running those Medicaid plans, a couple of things have happened. They have a lot more patients that need to be taken care of, which means they have to increase their ability to service those patients, manage those patients, communicate with those patients, all of the things they need to do normally when they're dealing with their Medicaid program that they're helping to run. So the covered lives have also changed because of this influx of patients, the budgets that they set, the people that they've assigned up all chains. So these payer organizations have to step up and figure out," Okay, what have we done in the past, who is coming into our programs and how do we need to shift what we're doing and how we're servicing these programs based upon this new population of patients coming in?" By the way, in many of the patients and families who qualify for Medicaid, they're multi- generational families living together, which means there is a greater increase in transmission of COVID- 19 amongst that group, and that clearly is going to impact the need for Medicaid services. And of course, also Medicare services, which is not related directly to payers, it's all government funded. So it's a problem for them. They also need to be able to distinguish between the COVID- 19 and non COVID- 19 patients, recognizing that the COVID- 19 patients get paid for by the feds and the non COVID-19 do not and need to be paid for with the Medicaid plan. How do you manage something if you don't know what's going on? How do you manage something if you don't have the statistics and the analytics to understand what's going on? And then on top of that, how do you manage something if you're not pushing down to the people who are actually doing the work to tell them what to expect, how things are changing and what initiatives they should take to manage populations. All of that is done directly through distributing analytics to the decision- makers and the frontline workers within payer organizations, the same applies for provider organizations, but in payer organizations so that they can be able to service those members as best as possible.

CG Adams: Dr. Chaiken, we've covered a ton of ground today, to close, what are the biggest insights we've seen that can be leveraged for payers to manage the next wave of the pandemic from an analytics perspective in your opinion?

Dr. Barry Chaiken: Well, first thing I want to share with you, there is not going to be a next wave. We are in this wave, and this wave is going to go on and on until we get better control of it. That's the reality. So what we have to recognize is that we're in for the fight, this summer isn't a time off for any of us, and that flu season is just around the corner and we are in this first wave and we're going to continue to need to fight and crush this pandemic.

CG Adams: So how do we achieve that? What needs to happen so we can successfully bring an end to the pandemic?

Dr. Barry Chaiken: Well, for payer organizations, what they need to do is let's go back and look at what's happened in previous flu seasons, let's do a variety of modeling between best case and worst case. Let's overlay that with what we have learned that has happened in New York, in the Northeast, back in March and April in the Spring, and let's understand what's happening in the Southern part of the country in the summer. We take those two things together, or three things together, we can have a better understanding what we can expect in the fall. And then what do we do? We prepare for it. Payer organizations are looking at those different scenarios and making sure that they have in place the resources and the people to be able to service the populations as things come along. When you have rapid change like this, you need more data analytics, not less. And what you need is you need to have, in your organization, a level of data literacy that people understand what data analytics and dashboards and visualizations mean, you need to have a culture of data so that people understand and accept data as being something that they should rely on to make their decisions. They should make their decisions on science and data and analytics, which helps them do a better job. They should understand that when things are changing like this, their needs for innovation. And its innovation, not only in the thinking of how they're going to address a problem, but innovation and how they use and apply analytics. That also leads the idea of embracing predictive analytics, looking at the past and trying to predict through your modeling, what will happen going forward. That means a best case, worst case, and maybe something in the middle. It's always better to be prepared for something and then be surprised by it. I always like to tell the story of I always carry a lot of gear when I go climbing in the mountains, not because I expect to use it, I'm hoping never to use it, and the same applies here. You prepare for the bad so that when the bad doesn't come, you're very happy. And if it does come, then you're at least prepared to deal with it. Maybe we can develop a pill that we all can take that protects us against the virus, but we don't know if any of this is going to happen, so let's prepare and make sure that we're agile and we can adjust to what we need to do to be safe. The reality is change is everywhere. Human beings have been incredibly successful on this planet earth because of their ability to adapt. And I think even with COVID-19, SARS- CoV- 2 virus, this pandemic, all the challenges that we have, we, as human beings, our strength is our ability to adapt and as human beings, I think we'll do really well. We just need to understand change is everywhere and we need to change with it.

CG Adams: Dr. Chaiken, thank you so much for joining us today on the Payer Principle podcast and for all of your insights.

Dr. Barry Chaiken: Thank you so much for having me.

CG Adams: To learn more about our payer solutions, visit salesforce. com/ healthcare. I'm your host CG Adams. Thank you for listening.