Recovering and Thriving Post-Pandemic: Part 5 - Health Plans and Payers

Contributors: Wren Keber, Lisa Soroka, and Z. Colette Edwards, WG'84, MD'85
To learn more about Wren, Lisa, and Colette, click here.


As we have done in previous articles in this series, in Part 5 we will continue to focus on activities healthcare leaders (specifically health plans and payers) can adopt to help ensure financial and operational recovery from the impacts of the COVID-19 pandemic. Simply put, this has been a rollercoaster of time for all - payers, providers, and patients/members. Hopefully, at this point, we can envision a time beyond the pandemic phase.

But the endemic and post–COVID stages may prove to be exceedingly costly, as we will discuss below. We will again outline relevant tactics as the pandemic/endemic/post-COVID phase continues to strain resources by creating constantly changing demands and high costs.

Early in the pandemic, many organizations reported health plans and payers were benefiting from the drop in utilization. This may have been true for a short period, when pauses in elective procedures reduced medical expenditures, and fear of contracting COVID-19 in clinical settings prompted patients to avoid emergency rooms and/or reconsider or postpone diagnostic, chronic, and routine care. As utilization has rebounded, payers are grappling with the widespread impact of pent-up demand, increased utilization, and a population with more comorbidities due to a delay of necessary care. In order to plan well enough for anticipated endemic and post-COVID costs, health plans should consider the following tactics as they plan for the future.

Evaluate the impact of long COVID. Research is ongoing and increasing to help understand and evaluate the current unknown impact on the long-term outlook of members suffering from long COVID. Early indications signal this post-viral syndrome may be difficult to address, and providers are often insufficiently aware and/or struggle to promptly diagnose patients with long COVID, who frequently present with a complex constellation of symptoms which might typically be attributed to any number of other root causes. Long COVID can result in a higher cost of care and has already increased medical debt for consumers as well as created challenges relative to disability insurance coverage.

Currently, the number and breadth of clinical pathways (i.e., diagnosis and treatment protocols) have grown significantly since the first reports of long COVID. However, given the reality that COVID-19 can impact the entire body and all organ systems, there is much more to be learned. Due to the multiplicity of symptoms, identifying the optimal care provider or care team members may not be clear. Consequently, patients may experience an increase in unnecessary and potentially costly referrals, a delay in care, and medical gaslighting.

A diagnosis code for long COVID was not released until the end of October 2021, and the varied constellation of symptoms may result in use of codes related to a patient’s presenting complaints without inclusion of the code which specifically flags long COVID. Additionally, since one can develop long COVID without ever having had symptoms at the time of initial infection (as well as in a reinfection or breakthrough infection scenario), the possibility of long COVID may not enter the mind of the patient or treating provider.

These challenges further contribute to the difficulty in quantifying the number of patients suffering from the condition, identifying approaches to symptom management, and even making the diagnosis in the first place. Health plans would be well served to:

  • follow the research and guideline development closely and proactively develop predictive analytics schemata to identify the size of the population suffering from long COVID in order to evaluate clinical and programmatic needs as well as the financial impacts of long COVID on the Medical Loss Ratio (MLR)
  • identify and provide coverage of services received at long COVID clinics (special care team expertise and holistic, integrated, coordinated care for patients with long COVID)
  • offer second opinion consultation to help with diagnosis and treatment recommendations
  • focus medical directorship on the design of care management programming, benefits, and resources to provide support to members with this often perplexing condition

Stay on top of the quickly evolving COVID-19 landscapeas its speed of change could continue to overwhelm already over-stressed providers, health plans, and payers. Lack of understanding of the complexity and uncertainty of long COVID by underwriters could significantly impact health plans and payers by underestimating the cost of care and reserving insufficiently. Costs due to a delay in care (resulting from patient conditions worsening because of lack of provider awareness and/or understanding of long COVID) could easily surpass cost savings realized by heath plans and payers when patients were not seeking necessary care.

And the cost of care will also be increased by the reality that those who have had a COVID-19 infection may develop new-onset depression, diabetes, and anxiety to name a few conditions that have been noted thus far (even in those who do not go on to develop long COVID). Additionally, increased pandemic-induced emotional distress and mental health conditions only exacerbate new or already existing physical health issues as well as preexisting behavioral health challenges. Tactics include:

  • providing ongoing education to network providers and members to raise awareness and enable a timely, accurate diagnosis to help decrease the twirling patients are currently experiencing when they engage with the healthcare system
  • paying close attention to what is happening world-wide to help anticipate future twists in the road. 

Ensure that care management is well-functioning to support members who have had difficulty being adherent to care plans. Because many patients were unable to follow many components of a care plan during the height and subsequent surges of the pandemic, risk profiles may have changed – sometimes becoming more acute – and new conditions may have developed. This heightened risk of an emergency event/hospitalization is exacerbated even further with concurrent mental health conditions, such as pandemic-induced depression and anxiety. Care management becomes even more critical to help members get back on track and identify the resources needed to optimize their health and well-being. Health plans will find it beneficial to:

  • embark on a comprehensive member outreach campaign to ensure pandemic-impacted individuals know how to re-engage with the delivery system and health plan resources
  • screen members for behavioral health conditions during care management to connect physical and mental health needs
  • re-score patient profiles regularly to help ensure care plans are appropriately tailored to clinically appropriate resources now required by changing health risk patterns and member needs
  • provide guidance to delegated care management arrangements on engaging members eligible for such programs, identifying new opportunities and the need for new offerings and potential changes to eligibility criteria, as well as communicating successes between plan and delegated functions.

As always, grow market share to further diversify risk pools. Ensuring consistent coverage for enrollees is important in reducing risks of avoidable acute health events, increasing utilization of preventive care, and optimizing the management of chronic conditions. This approach is essential when it comes to making health insurance coverage as affordable as possible and to manage the cost of care across the healthcare system in general.  Health plans should:

  • continue to learn and utilize evolving best practices in care management, service delivery, customer engagement, and Customer Relationship Management (CRM) systems to retain current members (a significantly lower cost alternative to attracting new members)
  • when possible, continue to invest in marketing and enrollment efforts targeted to younger, healthier populations, and, for Commercial health plans, to young adults who may otherwise choose not to purchase coverage.

In conclusion, we believe health plans and payers have multiple opportunities to address continuing clinical and financial challenges created by the pandemic. Specifically, we have provided several tactics which can be employed to speed recovery and mitigate the far-reaching impacts of COVID-19. Over time, these changes could dramatically improve quality of care, clinical outcomes, financial performance, member retention, new member enrollment, and member satisfaction, to name a few.

Recovering in an environment of a continuing pandemic, endemic, and/or post-pandemic world will require ongoing innovation, new as well as enhanced skill sets, proactive planning, and concrete actions to recruit and maintain a diverse healthcare workforce in a sustainable fashion, buttressed by a focus on the health and well-being of both clinical and non-clinical staff. These investments are critical to redesigning a financially stable delivery system that can consistently offer high quality care and meaningful improvements in clinical outcomes in the face of future COVID-19-related costs and potential healthcare crises which may erupt without warning.

Contact Wren at: [email protected]
Contact Lisa at: [email protected]
Contact Colette at: [email protected]