Industry

‘Tis the season. Reflections on 2021 and the storm brewing for health plans in 2022.

Posted November 18, 2021
By Jessica Bonham-Werling

This is the time of the year that health plans reflect on Q3 results and fully launch their open enrollment plans that have been in development over the last 9+ months. In a couple of weeks, enrollment windows will end and many health plans will gladly hibernate until the arrival of 2022. Around the 2nd week of January, they will awaken, feeling like they have been shot out of a cannon as work on 2022 goals become a reality. I worked at a major health plan for 6 years, and this happened every. single. year. Somehow, it always surprised me.

Before the hibernation begins, we thought we’d take a moment to reflect on 2021 and what can be expected in 2022, to make that post-holiday season wake-up call a little less jarring.

Things have been good for health plans, but weird, real weird.

2021 has been another weird one, for us all, but especially for health plans who have experienced some high highs and low lows due to the COVID-19 whiplash that was (is?) 2021. Most national plans have seen enduring financial gains as members continue to avoid the doctor and/or defer treatments due to COVID-19. These gains have been partially offset, however, by COVID-19 testing and treatment costs, and by declines in commercial member enrollment. While the year has been unpredictable, most plans are reporting overall strong results through Q3. Many have indicated they expect a decline in performance in Q4 as things normalize and members return to the doctor to receive care. It remains to be seen when “normal” will actually arrive, but it seems certain that the huge financial benefits that health plans have enjoyed in 2020 and 2021 will soon come to an end.

Winter is coming.

In many ways, the last 21 months have given health plans a bit of a reprieve from the arrival of strong storms ahead, but make no mistake, winter is coming. Market disruption is brewing from all angles. Consumers are more empowered than ever and will continue to demand better experiences. Consolidation is occurring across the care continuum. Digital-first payers are chipping away traditional health plan value propositions.  Tech giants are entering the space. 2022 will be a big year for health plans to make progress on their digital transformation plans in a bid to remain competitive as the storms arrive.

Health plans can take shelter with TEFCA, FHIR, and Redox.

The good news is that health plans do not need to bear the brunt of the storm alone. Major interoperability progress is expected in 2022 as version 1 of the Trusted Exchange Framework and Common Agreement (TEFCA) will be finalized in Q1 and Qualified Health Information Networks (QHIN) are expected to be operationalized by the end of the year. It is predicted that TEFCA will enable efficient information sharing so health plans can improve care coordination, close care gaps, and enhance their value-based care and population health initiatives. Many also hope that TEFCA will set a roadmap of sorts to accelerate the adoption of the Fast Healthcare Interoperability Resources (FHIR) standard throughout the healthcare industry.

With this in mind, Redox has been hard at work launching our FHIR API to help payers, providers and other healthcare customers fully embrace the new standard as it becomes a reality. The Redox platform will also continue to fully support sending and/or receiving older ONC standards like HL7v2 and X12, while widespread FHIR adoption is in progress. This allows payers to prepare for, and inch towards the future without jumping off a cliff or incurring unnecessary technical debt. Our Sr. Developer Nick Hatt recently hosted a tech talk on the underpinnings of FHIR and requirements for payers.

Redox has also created adapters to help transform data from any standard into FHIR for easy loading into AWS Healthlake and Microsoft Cloud for Health so health plans, providers, and others can securely manage and analyze data at scale.

Don’t let the uncertainty of the storm knock you off the compliance wagon.

Finally, 2022 will also bring the next set of deadlines on CMS Patient Access Interoperability rules, beginning with the Payer-to-Payer data exchange mandate in January. While CMS has indicated they won’t enforce this rule until more clarification is provided, payers can start to make progress on this mandate by adopting a flexible solution that takes a networked approach to interoperability. Payers should also plan to make progress on implementing electronic prior authorization solutions in 2022 as the proposed CMS Prior Authorization Interoperability rules are likely to be finalized. We cover how Redox supports both Payer to Payer and Prior Authorization mandates in our recent Redox for Payers product launch. Our solutions will help payers prepare to be compliant in the future while reaping the tremendous benefits that can come from interoperability now.

So, with these things in mind, we wish you a very happy end to the open enrollment season and a short winter’s rest. When you get shot out of that cannon in January (or before!), get in touch to learn more about how Redox can help provide some cover from the coming storms.