The top four challenges and opportunities facing health plans today

The healthcare landscape has shifted significantly in the last several years. How have those changes impacted forward-thinking health plans’ strategies? Our chief growth officer explores this question and more in the interview below.

John Hastings has spent more than 20 years in the healthcare industry. In his role as chief growth officer at Carelon, John and his team have the opportunity to work with many of the leading health plans across the U.S.

In the conversation below, John talks about the complex challenges that health plans face today — and how leading health plans are prioritizing strategies to:

• Improve healthcare affordability
• Drive better quality and outcomes
• Improve the member and care provider experience
• Optimize operational efficiency to enable innovation
   

You work closely with senior leaders at some of the country’s top health plans. What challenges are they facing today?

Across all lines of business, health plans are trying to succeed in an increasingly competitive market and deliver better experiences. They are focusing on having the most intuitive, personalized, and seamless experience for members and care providers.

Driving quality is another priority for health plans. That includes getting ahead of members’ health to help them stay well and helping those members with acute and chronic issues get the right care. To do that, health plans need to identify the right people, engage them, and stay very connected to them.

Finally, heath plans are highly focused on cost of care. They need to have very strong offerings to address affordability while making sure members have access to quality care.

There are a lot of complexities involved in those efforts. Health plans are looking to streamline, become more efficient, and work with partners that can support these business goals.
 

Since Carelon launched in 2022, the healthcare landscape has changed immensely. What changes are top of mind for health plans right now?

It's a very competitive time for health plans. Over the past several years, a tremendous amount of capital has poured in from private equity firms and venture capital, and many startups have emerged.

As a result, health plans really do need to maintain as much of their provider and member interface as they possibly can, because that drives a more seamless, integrated experience. When too many disconnected point solutions are involved, getting the complete view of a member’s whole health becomes incredibly difficult.
 

Are forward-thinking health plans responding to these changes differently than other health plans?

Based on my conversations, relative to others in the market, high-performing health plans tend to do five things in particular:

1. Embrace technological innovation. From digital tools to advanced technology, leading health plans invest heavily in innovation to improve care delivery, streamline operations, and enhance member experience.
2. Prioritize value-based care across the organization. The leading health plans are moving away from fee-for-service models and focusing on incentivizing outcomes rather than volume.
3. Adopt a proactive, holistic approach to member health. This strategy addresses social drivers of health and involves comprehensive care models that consider all aspects of a member's life, not just episodic clinical needs.
4. Think about partnerships in new ways. They seek out active collaboration with care providers, technology companies, and community organizations to deliver more-coordinated, better-personalized care.
5. Double down on member engagement. Lastly, top health plans leverage tools like apps, telemedicine, and other digital channels to engage members in managing their whole health and well-being.

Collectively, these practices are helping these health plans stay ahead in the competitive landscape and provide better outcomes for both members and the organization.
 

What is Carelon doing to help health plans not only manage these changes but also advance the Triple Aim?

It really starts with our capabilities being able to support whole health — including physical, behavioral, and social drivers of health — and the entire care journey, from care navigation to post-claim services. We scale that support in many ways, including:

• Combining clinical knowledge with data and analytics to support clinical decision making so members receive the right care in the right setting at the right time.
• Helping to manage medications, including specialty drugs.
• Partnering with life sciences firms in conducting research to generate insights and, in essence, uncover the next generation of medical evidence.
• Delivering tailored care, like palliative care, to individuals with chronic or complex conditions.
• Working to remove friction in the system for both individuals and providers, making the healthcare system a more intuitive, personalized, and guided experience.

Many of our solutions also address affordability. Our use of analytics to strengthen payment integrity is just one example of how we provide a strong ROI for health plans. And we are continuously innovating and growing our capabilities to be a trusted partner to health plans, one who can meaningfully support their operating efficiency while also improving experiences for their stakeholders.

While health plans share common challenges, each one is unique, serving particular employers and particular member populations in their respective markets. Success requires us to understand their needs and support them with flexible, customized solutions. Luckily, we are designed to do just that. You can think of us as the engine enabling health plans to drive their performance.