As a new year approaches, the U.S. healthcare industry faces converging factors that signal some significant upcoming changes.
- An estimated 60% of adults have at least one chronic disease, and 40% suffer from two or more, straining healthcare resources.
- In 2023, life expectancy declined to 76.4 years, due in part to social inequities and to a healthcare system that has long prioritized cure over prevention.
- Many providers are still generally operating under a fee-for-service model where compensation is based on service volume instead of the value and quality of the provided care
- Evolutions in technology for healthcare services have increased costs for some services and items.
- Healthcare costs have continued to rise and by the end of the year, the country is estimated to have spent a projected $4.7 trillion (or 18 percent of the national economy) on healthcare in 2023.
- Regulatory guidance efforts aimed at shaping outcome-driven, value-based healthcare delivery are in progress (or already taking effect).
One thing is clear for 2024: The need to invest in prevention-focused, whole-person care is becoming a mainstream battle cry rather than a fringe murmur. Value-based care is now a necessity to function effectively and efficiently in today’s modern healthcare space.
Below, we explore the six healthcare trends we see being top of mind for 2024. And they all point to a future where care management and utilization management are aligned, bolstered by data-driven insights, intelligent automations, and configurable workflows and rules engines. And in this future, we see what VirtualHealth believes is critical coming into focus: Keeping patients at the center so as to deliver the safest, most effective care possible.
1. Alignment of Care Management and Utilization Management
Alignment of care management and utilization management (UM) can result in more efficient, effective, and transparent delivery of care – and it’s a key step in achieving the connected healthcare ecosystem of the future. This is going to be the biggest goal for organizations we think in 2024 as recent changes to UM rules and regulations will emphasize the need for solutions that combine both.
UM data is a valuable resource for care managers, who can use it to develop more effective care plans for members or to intervene proactively when needed. For example, suppose a care manager is aware of a prior authorization for an upcoming procedure. In that case, they can begin engaging the member in tailored pre-op education and preparation to optimize surgical outcomes.
Payers can help facilitate better information exchange with shared dashboards and collaborative tools that integrate UM and care management activities. With all data in one place, teams can work in collaboration instead of in silos, resulting in better decisions for members and cutting down on costly, time-consuming redundancies. It’s part of why some companies this year have opted for HELIOSum.
2. Data Interoperability
Data interoperability has been an issue for a long time, but for 2024 it’s at the top of the list for stakeholders across the industry.
- Patients are demanding better access to their own health information.
- Frontline clinicians need reliable, accurate data so they can make the best treatment decisions. (96% of physicians said better access to patient data could improve safety and save lives, according to a Google Cloud survey.)
- And healthcare payers need interoperable data to enable collaborative, team-based care.
Many healthcare organizations are also working toward being in compliance with new CMS regulations requiring data to be compatible with the HL7® FHIR® standard, which provides a common framework for data exchange between multiple sources. (See how you can do this and expedite data integrations by 65% or more here.)
But converting inbound data sources to FHIR®-compatible formats has its challenges, and it’s why VirtualHealth created HELIOShub. As the first FHIR® integration platform as a service (FiPaas), HELIOShub helps organizations achieve FHIR® -compatible data faster and without draining IT resources so that they can share uniform data across the care continuum and enable truly connected, collaborative care.
3. A Collaborative Care Approach
One of the things we’ve heard from talking with organizations this year is a desire to improve collaborative care and create stronger relationships with providers. Both these will help to improve care, health outcomes, and overall cost savings. (Need further proof? One study found that a collaborative, interdisciplinary approach resulted in a 16.7% reduction in emergency department visits and a 17.7% reduction in hospitalizations.)
This year, we’ve seen the following needs be listed under collaborative care, and we think they’ll be critical items to address for 2024:
- Risk stratification
- Multidisciplinary user support
- Automated and configurable workflows to smooth the transition of patients across care settings and providers
- Source of truth for patient information and data
- Concurrent reviews
- Integrations with claims systems, provider portals, and organization-specific systems to enable regulatory compliance and data connectivity
Organizations Participating in the Making Care Primary Model Have Further Incentive
CMS’ Making Care Primary Model, announced earlier this year, aims to improve collaborative care among primary providers and specialists, including behavioral health and social services professionals. It’s a harbinger of the agency’s continuing drive toward value-based care, as well as outcome-based payments. For the state organizations who participate in this program, a collaborative care approach supported by tech will be key. (See our Making Care Primary Model blogs for more information: blog 1, blog 2, and blog 3.)
In 2024 and beyond, achieving collaborative care will depend on a connected digital ecosystem, with cloud-based technologies and integrated data sources. This is what facilitates team-based decision-making: the ability of all involved in a patient’s care to access the data they need to stay in sync on emerging events and diagnoses, new treatments, procedures, medications, test results, and social/lifestyle factors that influence clinical health.
4. The Rise of Alternative Payment Models
Perhaps one of the clearest indicators of the shift toward value-based care is the rising prevalence of alternative payment models (APMs). In fact, 41.3% of healthcare payments in the U.S. last year were linked to APMs, according to a survey by the Health Care Payment & Learning Action Network. Medicare Advantage had the highest amount, with 57.2% of health care payments tied to APMs. About 72% of health plan leaders who were surveyed said they believe that APM activity will increase in the coming years.
Making Care Primary participating organizations will also be pushed to move away from any existing fee-for-service models and completely move to a fully prospective, population-based payment model.
5. The Potential of AI
Momentum also continues to escalate regarding the application of AI in healthcare. Statista predicts that the AI healthcare market will grow to $187 billion by 2030. (It was valued at $11 billion in 2021.)
At VirtualHealth, we believe the most compelling aspect of AI will actually be the enhancements it enables within existing healthcare technology related to predictive data and analytics, smarter decision-making, more predictive modeling for patients and care plans, and other preventive care efforts.
We also believe we’ll see AI helping to further automate manual processes that will deliver greater care team productivity and efficiency. Analyzing complex data to generate suggestions for the next best action to take. Predicting population health needs. This is what’s exciting about the potential of AI.
Yet, along with AI’s benefits will come risks. Protecting the security of private health information is one. Over-reliance on the output of AI is another. Healthcare professionals need to be in charge of the machine, not the other way around, to ensure the validity of the suggestions generated. We echo Gartner’s stance on adopting AI, as stated in the organization’s October 2023 report U.S. Payer and Provider CIOs: Apply AI in Care Management Programs: “Measured, strategic investment is critical, and not succumbing to the hype of this emerging market is key.”
6. Expansion of Holistic and Preventive Care
And finally, 2024 will see more health systems and plan providers expanding holistic care. Specifically, we foresee the continued inclusion of more services related to:
- Behavioral health
- Mental health
- Healthy lifestyles
- And social-related health factors (i.e. addressing social determinants of health)
All of these are being recognized as an essential part of improving clinical health outcomes. Moreover, CMS is making better access to behavioral and mental health care a formal priority with its Behavioral Health Strategy which is intended to expand access to these services for Medicaid and Medicare members.
As a result, we expect 2024 to see a growing emphasis on prevention and member engagement, including coaching patients on exercise and nutrition, as well as the integration of more holistic services and connected community programs or telehealth technologies.
Health Tech Offers an Opportunity for 2024
With these six trends on the horizon, it’s a good thing that the rise of new healthcare technologies is also happening on the back end with innovation in care management and utilization management solutions like HELIOS to help healthcare organizations transform the system.
For example, HELIOSum is helping align care management and utilization management to help healthcare payors reduce costs related to inaccurate prior authorizations, reduce care delays, eliminate inaccuracies, and improve overall care experiences for plan members. And while HELIOSum is doing this, the new data interoperability application HELIOShub is taking down data siloes by helping organizations eliminate disparate data technologies, services, and formats to provide an integrated FHIR® transformation and interoperability platform for achieving organization-wide data sharing and uniformity.