After spending more than a decade in the Payer technology space, Namrata Dhanawade knows what it takes to make benefits more innovative and easily operationalized. Listen to her, share her thoughts on the trends impacting the ACA market today and how Healthcare Payers can be prepared to face future challenges.

There is tremendous pressure on Payers to support revenue growth, improve the customer experience and increase healthcare quality. Part of the journey towards digital transformation includes AI and automation for Small Group and Individual Payers. Like it or not, digital transformation is going to play a pivotal role — fuel, drive, and sustain future growth of the business for Small Group and Individual Payers. — Namrata Dhanawade, VP Strategic Solutions, Simplify Healthcare

Listen to the Podcast

Transcript

Anuradha Menezes: Welcome to the Simplify Healthcare podcast. My name is Anuradha Menezes — I work with the Digital Experience team here at Simplify Healthcare. The focus of our podcast today is on Individual and Small Group Healthcare Payers and the trends that are impacting the industry today.

I want to welcome our guest, Namrata Dhanawade — Vice President of Strategic Solutions at Simplify Healthcare. Namrata, would you mind introducing yourself to our listeners?

Namrata Dhanawade: Sure, thanks, Anu. Hello, everyone! Thanks for taking the time today to hear about our thoughts on some of the trends in the ACA market space. I have spent about a decade learning about benefits, what it does, and what it takes to make them more innovative and then, of course, easily operationalized. I’ve also always been interested in data, whether it’s parsing it for a pattern or formulating logic that would automate transformations, so I’m very happy to be here to talk through some of it.

Anuradha Menezes: Thanks for the introduction and for taking the time to speak to our listeners on this podcast.

Let’s get started with the first question. What are some of the trends we are seeing in the Individual and Small Group market? And do you think some of the trends that we’re seeing now are here to stay?

Namrata Dhanawade: Specifically, in terms of Individual and Small Group Health Plans, as we know they are not required by law to purchase and/or provide health insurance coverage. Since it is not a requirement, Payers looking to enter the small business market need to carefully think through their strategies to make these Health Plans appealing and cost-effective. Historically, the percentage of small firms offering employee group insurance has declined dramatically. In 2000, about 50% of small businesses offered coverage to their employees. In 2019, this figure dropped to 31%. On Individuals, from my own experience when I was much younger, and didn’t feel the need to purchase insurance, I know how difficult it was to find something that was low cost but still enough value.

Anuradha Menezes: What do you think are the major challenges here?

Namrata Dhanawade: It becomes a challenge to provide flexible benefits and cost-saving strategies that create value for small businesses and for individuals researching to find the best options in the market.

However, rising costs in this market and decreased enrollment in many states have made the Individual and Small

Group Market less attractive to Payers, small business employers, and employees.

In some states, small group employers are at a crucial stage — in such cases small employers are actually paying higher premiums for lower value plans.

Diving a bit into Small Group insurance, this is a great market opportunity for businesses. It often serves as a recruiting tool to attract new employees, an incentive to retain employees.

Anuradha Menezes: Do you think cost is still a major barrier for individuals who want to buy insurance?

Namrata Dhanawade: In the case of Individual plans, cost is a major barrier for individuals, despite the ACA making great gains. During the pandemic, Payers needed to make a quick pivot building individualized Health Plans in the backdrop of many Americans losing their jobs and therefore losing their employer sponsored insurance. Demands were high for discounted or short-term plans to manage medical emergencies. Payers had to deal with numerous cost-of-care scenarios.

Anuradha Menezes: Is healthcare coverage still top priority for small businesses?

Namrata Dhanawade: Healthcare coverage continues to be a priority for small businesses. Almost 90 percent of small business employers said that employee health and wellbeing was one of their primary concerns in a survey conducted by Cigna and Oscar Health Foundation last year.

However, there is a line of caution here that Payers wouldn’t want to cross. Small businesses may not be encouraged to provide Healthcare coverage for employees if they thought a Health Plan was too expensive, was inefficient, or incompatible with the needs of a business’ employees.

Anuradha Menezes: What can Small and Individual Health Payers learn from a crisis situation like last year’s pandemic?

Namrata Dhanawade: There are various crises that have come and gone before and have impacted the Healthcare insurance industry. Payers can learn from history and even use historical data from a past outbreak to respond as quickly as possible. The faster you can respond, the more you make it possible to mitigate changes in cost and utilization of healthcare services that can go out of control in any crisis situation. The important thing is to respond in a timely and accurate manner.

These circumstances can generate new documentation and additional tasks for managing Healthcare coverage, alongside the standard procedures and existing IRS filing requirements that an employer must follow to form a Qualified Health Plan, or a QHP.

I think Health Plans are recognizing that Individual and small benefit products are getting more and more complex. At the same time, Individuals and Small Group employers are growing to be more demanding, wanting an array of choice benefits for product offerings. The market has become more competitive than ever. Health Plans are realizing that the current method of operation is simply not sustainable and cannot compete effectively.

Anuradha Menezes: What do you think are some of the problems and what could be the solution here, Namrata?

Namrata Dhanawade: Just about everyone is facing uncertainty and some insecurity related to health, family, job security, and the economy. There are bound to be short- and long-term effects on Payers that are complex and will need to be thought through. The new regulations from the No Surprises Act can cause strain in relationships between Individuals, Employers, Payers, and Providers. However, some of the major struggles Small Group and Individual Payers might be facing are in areas like:

  • Remote health service — issues like risk adjustment, compliance, and regulatory issues, cybersecurity needs to be considered with the shift to telehealth services — can you still deliver high-quality care for everyone? There is a form of care that makes us feel cared for — which does not come from a virtual connect
  • Pharmacy landscape changes — the pandemic has had an impact on formularies, rebates, market dynamics and regulatory changes and all this can impact a Health Plan’s current and future pharmaceutical expenses.
  • Reporting is another aspect that can prove to be challenging with changing regulations.

There is a need to bring automation into the process if you want to reach the markets effectively or even if you want to add on new markets in order to expand.

Anuradha Menezes: So how do you see Small and Individual Health Payers competing in such a market?

Namrata Dhanawade: Small Group and Individual Health Plans will need to work harder to gain market share in such an evolving landscape. There was a study from Accenture that came out last year called “The Future Belongs to Intelligent Payer Operations”. It talks about how intelligent digital transformation can pave the journey toward success for the Payer market. And I think it hit the nail on the head. That’s the key here. There is tremendous pressure on Payers to support revenue growth, improve the customer experience, and increase Healthcare quality. Part of the journey toward digital transformation includes AI and automation for Small Group and Individual Payers — nearly 75% of the 150 Payers that Accenture surveyed echoed the need. Like it or not, digital transformation is going to play a pivotal role — fuel, drive, and sustain future growth of the business for Small Group and Individual Payers.

Anuradha Menezes: And on that note, we need to wrap up this episode. Namrata, it’s been great having you on the show. Thanks for a good discussion. Thanks, everyone for listening to the podcast. We hope you join us next time for another interesting conversation. Stay tuned!

For a more detailed discussion about our solutions and how we can help your business:
GET IN TOUCH