How Do Payers Approach Care Management Strategies, Technologies?

Payers’ role in care management

As administrators of health plans, payers are in a position to facilitate member access to care management programs. For example, payers could offer financial incentives to encourage members to join care management programs. Payers may also provide coverage of care coordination services to improve access to affordable care.

Adequate care coordination requires a reliable provider network, which payers have a hand in picking. By contracting with and establishing a network of quality providers, hospitals, and specialists, payers can help members access appropriate services across their care continuum.

Health plans can also employ outreach strategies to inform members about preventive care and care management programs.

According to McKinsey & Company, the COVID-19 pandemic led payers to rethink how they approach care management. The management consulting company found that, as of January 2021, many payers were dedicating 10 percent or more administrative spending to care management but were not seeing a return on investment (ROI).

To improve the ROI on care management, McKinsey recommended payers target both medical cost and revenue sources of value. In addition, payers should craft their care management intensity to reflect the needs and spending of a targeted population and run care management strategies with an operational mindset.

Using technology for care management

Technology capabilities can make care management initiatives simpler and more efficient. Digitizing tasks such as calling members and using automation to assign members case managers can help relieve administrative burden and minimize time spent on manual tasks.

Electronic health records (EHRs) are also important for care management, as they allow payers and providers to access patient health data that can inform decision-making. Similarly, health information exchange (HIE) systems allow patient health information to travel between different healthcare providers and organizations.

The use of telehealth and virtual care technologies took off when the pandemic hit, with healthcare stakeholders realizing their potential even after in-person care was allowed again. By offering members access to telehealth services, payers can expand population health management interventions and enable providers to interact with more patients. Virtual tools like symptom screeners and chatbots can also improve triage.

Like many aspects of healthcare, care management can benefit from data analytics and artificial intelligence. Data analytics tools like predictive modeling can help payers identify high-risk patients and allocate resources.

Additionally, artificial intelligence can assist with identifying low-risk members, which helps payers prevent them from moving into the high-risk category. After using artificial intelligence tools to determine members needing care management, payers can leverage additional technology solutions to address members’ specific conditions.

Top care management vendors

Payers often connect with third-party vendors to access these technologies for care management. As healthcare evolves, payers have started seeking vendors with solutions supporting behavioral health initiatives and automated prior authorization.

According to the Payer Care Management section of the 2023 Best in KLAS report, ZeOmega was the highest-ranked vendor, with a performance score of 82.9. The vendor’s care management software, Jiva, received the highest score for customer loyalty, with an A-. The software received a B+ for relationship, a B for product, a B- for both operations and culture, and a C+ for value.

In a separate KLAS report, ZeOmega users recognized the vendor’s responsiveness to payer regulatory changes and its broad support of use-case functionality.

HealthEdge’s GuidingCare software was also popular for care management, receiving an overall performance score of 75.8. Users have indicated that the vendor offers quality functionality for traditional care management use cases.

Payers who use Gainwell Technologies noted that the vendor’s solutions assisted with behavioral health, pharmacy management, provider engagement, and telehealth use cases.

Payers have also leveraged Zyter|TruCare's Care Management Software and Medecision's software Aerial for care management solutions.

editor's note - This story was updated on 9/14/23 to correct a vendor's name. A previous version said "Casenet's software TruCare" and the name has been corrected to "Zyter|TruCare's Care Management Software."