How Health Plans Can Future-Proof Their Business
Anyone who has visited Walt Disney World has undoubtedly toured the park’s Carousel of Progress. The carousel, which debuted at the 1964 World’s Fair, shows futuristic settings of the American home from different time periods, highlighting how advances shape our lives. It’s a provocative journey that asks visitors to think about how life could be different — presumably better — using new technologies, creativity, and ingenuity.
Inspired by this, Oliver Wyman set out to define the TOMORROWPlan, a health plan designed to thrive in and shape the future of the US healthcare environment. Our vision for TOMORROWPlan incorporates strategic and imaginative deployment of technology, better use of data, and new workforce models, among other things. Importantly, it does not cover potential macro shifts in how US healthcare is covered and paid for, like the creation of a single payer system or other significant policy changes. Our aim is to inspire US healthcare leaders to reimagine and shape a better future for healthcare, irrespective of policy debates.
This article spotlights key takeaways from our paper, TOMORROWPlan: Oliver Wyman's Healthcare Carousel of Progress, which can be found below.
Factors shaping the health insurance landscape
Before getting to TOMORROWPlan, it’s important to understand the pressures that are shaping today’s insurance sector. A record number of Americans currently receive health coverage through health plans, largely due to the Affordable Care Act, the growth of Medicare Advantage, and the expansion of Medicaid managed care. However, rising premiums and affordability concerns loom large. In a separate analysis, Oliver Wyman projected that healthcare spending could consume 30% of an average family's budget by 2035.
Compounding these challenges is the demographic shift toward an aging population, which will increase demand for health services as the working-age to senior ratio declines from 4:1 to 2:1. The rising costs of specialty drugs are causing additional financial strain for health plans. We are also seeing continued consolidation across the industry, with larger, more specialized plans emerging. Collectively, these market forces call for a proactive and innovative response from healthcare leaders.
Advances that make TOMORROWPlan a possibility
TOMORROWPlan envisions a future where advanced technologies and innovative practices are more thoroughly integrated across healthcare, creating a stepwise change in how health plans operate and in how customers experience them.
Our paper examines how health plans can transform operations across multiple functions. The front office will become more focused on delivering personalized recommendations for brokers, employers, and customers across the entire care journey.
In the middle office, automation of core operations is a priority. TOMORROWPlan reimagines how generative artificial intelligence can streamline menial tasks, such as handling routine calls, freeing up teams to focus on the most critical aspects of medical management.
In the back office, data silos between payers, providers, and pharmacy benefit managers (PBMs) are dismantled. TOMORROWPlan envisions instantaneous coverage determinations, automated claims adjudication, and the deployment of AI-powered agents to resolve problems and respond to customer inquiries more effectively.
These advancements lead to faster processing, greater accuracy, and a significantly improved experience for both providers and members. We also delve into transformation taking place with information technology departments and in the C-suite.
A few key advances make this vision attainable:
1. Artificial Intelligence as a necessity
The proliferation of generative AI tools inspires new possibilities for healthcare organizations. By implementing AI-driven operating models, health plans can enhance efficiency and drive value. Early adopters of AI have gained a competitive edge, rethinking workflows to optimize patient care and operational effectiveness.
2. Data connectivity and collaboration
Achieving true interoperability among electronic medical records has long been a goal in healthcare. The TOMORROWPlan emphasizes real-time data sharing across payers, providers, and patients, reducing redundant care and enhancing communication through a mix of data sharing requirements plus payer-provider collaboration.
3. Personalization and consumer engagement
The TOMORROWPlan harnesses digital tools and social media to build stronger connections with consumers. By leveraging health data, organizations can provide personalized guidance and treatment plans, fostering trust and engagement among patients.
4. Reimagining workforces
Successful health plans are investing in workforce education and reskilling to adapt to new technologies. By breaking down silos and fostering a product-oriented approach, organizations will redesign the work to enhance collaboration and improve the member experience.
Actionable Steps for Healthcare Executives
To successfully transition to TOMORROWPlan, healthcare executives need to go beyond cutting costs within existing practices and to re-think their operating models and sunset legacy operations and practices. It means moving away from the view that a single solution will solve all issues. Instead, they need to take a process-centric view for transformation. Across each business area, ask a few key questions: Can this be done better? Am I meeting my full obligations to my customers? Have I invested in the required technology capability
Gone are the days of constant back and forth on delivery requirements between business and IT – to deliver, a TOMORROWPlan has adopted a cross-functional and collaborative working model across the organization; the days of siloed teams are inadequate for tackling the complexities of modern healthcare.
Investing in generative AI and other technologies is also critical, while recognizing that the human-stack is more important than the tech-stack when it comes to driving impact with generative AI. As such, the use of technology needs to be driven by the organization’s strategic goals and the problems it is trying to solve. Cultivating the right talent model is paramount, too, as the modern workforce needs to be adaptable and equipped to face future challenges. By creating cross-functional teams that emphasize continuous learning, insurers can better prepare themselves for the evolving landscape of healthcare.
Making TOMORROWPlan a reality
The vision for TOMORROWPlan is not a distant aspiration; it is an achievable goal. But leaders need to embark on a series of incremental steps now to get there. By embracing the principles of the TOMORROWPlan, organizations can navigate the complexities of today's healthcare landscape and gain a competitive edge. The journey is not just about surviving the challenges ahead but about building an agile organization that can thrive in the future, regardless of ever-shifting market dynamics.
