One only has to take a glance at the evening news or peruse online articles to see that significant changes are bringing uncertainty and challenges to the U.S. healthcare system – for both payers and providers. Of course, these challenges also have a tremendous effect on how Americans access healthcare and whether care is affordable and thus in reach for most people in the country.

The Zelis Office of the Chief Medical Officer has its eyes on a number of trends as we head into 2024, trends that will greatly affect how healthcare is offered and financed.

Medicare Advantage  

This has become the predominant form of coverage for Medicare patients. Since managed care like Medicare Advantage passes along financial risk to payers and providers, payment integrity becomes ever-more important in assuring that claims are properly coded and paid.

Affordable Care Act (ACA) 

In this election year, the ACA will be a point of contention and discussion. The ACA resulted in the percentage of Americans without health insurance falling from 18.2% in 2010 to 8.8% in late 2022. If Republicans regain control of the White House and Congress, there could well be renewed attempts in coming years to repeal the ACA.

A replacement plan could result in rising numbers of uninsured. Swelling numbers of uninsured patients put pressure on providers to increase reimbursement from insured patients or to even cut services that are found to be less profitable. These actions in turn necessitate that payers assure that payments are accurate and push payers to collaborate with providers to ensure that desired services are available for the payers’ members.

Staffing shortages across healthcare  

The number of healthcare workers in the U.S. is falling. Starting at the beginning of 2021 through the end of 2023, the U.S. was on track to lose more than 200,000 healthcare workers and the new graduate pipeline is not nearly sufficient to replace them. This reality has led to staffing shortages across the country. Staffing shortages have several detrimental effects:

  • As the supply of nurses, physicians and other healthcare workers fails to meet demand, providers often must pay higher and higher prices to attract qualified professionals.
  • A 2022 report from Survey Health Global revealed that more than a third of surveyed physicians had observed increases in medical errors attributable to staffing shortages and the resulting constant stress. This same report pointed to longer wait times for patients that are also related to insufficient staffing.
  • Staffing shortages can lead to increased coding and billing errors while inadequate staffing of payers’ internal teams can interfere with assuring payment accuracy.

Artificial intelligence (AI) 

Advanced technology, including AI and automation, will remain important components in improving the speed and quality of healthcare and healthcare financing. However, it will not replace the need for the human touch.

Faster information systems will do no good if there are insufficient doctors, nurses and other professionals to provide the care. Beyond that, technology in its current state might actually be detrimental to certain aspects of healthcare. For example, physicians routinely point to electronic health records (EHRs) as a key source of frustration, as entering information into a computer system pulls them away from actual patient care.

In the realm of payment integrity, the human touch is necessary since AI in its current form cannot perform all of the complex and nuanced decision making needed for high-quality chart review. Human beings can also impact provider relations and interactions between payers and payment integrity partners much better than technology can alone.

But with great challenges comes great opportunity. Zelis is excited about the future of healthcare, and we look forward to working with our partners to modernize the financial healthcare experience for all.

If you’d like to talk to our team about payment integrity, you can connect with them here.