Researchers from global consulting company PwC say providers and insurers have ample opportunities, but also significant challenges in serving the roughly 30 million people who will become newly insured through Medicaid expansion and via the health insurance exchanges in the coming years.
But a key to serving the population is to have an understanding of who the newly insured will be, their employment status and their health status, as well as how well they understand and are able to navigate the healthcare system, said PwC researchers in a Tuesday afternoon webinar, "Health reform re-elected: The Sprint is on in 2013."
According to PwC, the newly insured will tend to be younger people (an average age of 31 years old) and will likely be employed part-time and of lower household incomes.
"We anticipate that current Medicaid managed care organizations could have a leg up – could have an advantage – in serving this population, because they have a track record and some experience working with individuals like this, handling outreach and communication," said Ceci Connolly, managing director of PwC's Health Research Institute (HRI). "When you look at education level, you look at employment status, you look at language spoken at home and what you can see is there are going to be big opportuntities in the exchanges."
How great are these opportunities? According to PwC's research it is anticipated that HIXes will generate nearly $205 billion in premium revenue by 2021, the vast majority of that total generated by the newly insured.
The potential of greatly increased plan membership is significant, but insurers and managed care companies need to be ready to provide the appropriate services to this population in order to succeed. That means leveraging the opportunity to provide better care coordination and even expanding services in this area to possibly include such things as arranging transportation to check-ups and appointments or creating a more robust and complete post-visit follow-up program. These efforts would go hand in hand with developing programs that effectively tackle disease prevention.
But with the opportunities come challenges. With many of the newly insured having received only sporadic care in the past, insurers and providers alike must find effective means of mitigating the potential for increased utilization of health services as well as finding an effective means of predicting the future health needs of the population.
Cultural and language training will also be a challenge, and a key to success in serving the newly insured, as it is anticipated nearly one-in-four will be a minority and more than 30 percent will speak a language other than English.
With the advent of the exchanges also comes a growing power of consumerism in the healthcare sector that has also been spurred by the growth of consumer directed health plans (CDHPs) that puts individuals more directly in control of their healthcare spending.
And as individuals have more direct control over their healthcare spending, a necessary shift will occur in how providers and insurers view their customers and set organization priorities.
"The customer is not a nuisance; the customer is the center of the wheel," said Todd Evans, director with PwC. "If there is no outcome, there is no income. Clearly customers have a direct impact on the entire system's ability to monetize quality and satisfaction in a way that is meaningful to everyone.
"We want to deal with the customer and the individual prior to them becoming a patient, particularly as we emerge from a fee-for-service world into population health management where we want to mitigate the full bloom of disease … and preventing people from entering an acute environment at all."