Hello, everyone. This is Jacob Emerson with the
Becker's Healthcare Podcast. Thanks so much for tuning
in today where we're thrilled to be joined
by Angie Adams, who is the vice president
of product management at I three Healthcare Solutions.
Angie, thank you so much for taking the
time to be with us on the podcast.
Thanks, Jacob. It's good to be here. So
Angie, before we dive into everything that we
wanna talk with you about, can you tell
us a little bit more about yourself in
terms of your background in healthcare, and what
it is that you're doing today at I
three Healthcare Solutions?
Sure.
You know, I I was thinking about this,
and I I realized that I actually started
my health care
career just out of high school at a
couple, you know, ophthalmology office and, another
optical store. But the bulk of my health
care experience
was at a health care payer called Magellan
Health in the provider network department. I worked
there for nearly 18 years, and I was
responsible
for many different things over the course of
that, the tenure at Magellan in various roles,
but all of them in the provider network
department.
I was in a pseudo technical role, but
from a business perspective, not in IT. And
I was responsible for making sure that all
of our provider data business processes were able
to support
the ever changing business needs that occur across
the country because Magellan was national. We had
a great deal of success, and, you know,
one of the things that was most critical
for us in that department was that the
provider data got everywhere, that all the different
areas got what they needed, whether it was
claims or eligibility
or clinical
or our provider portal provider directory.
And
making sure that our providers were well served
and things were simple for them, but also
that the members' needs were met and all
of that.
After leaving Magellan, I went to,
a company that is now I three Healthcare
Solutions
and worked in professional service implementing solutions from
a consulting perspective
for health care,
organizations, health care payers,
appeals and grievances, that sort of thing. So
I I leveraged that in that knowledge,
of health care and and expanded
my knowledge of of different areas in health
care. Today, I'm responsible
for the product management for all of I
three health care solutions,
and our solutions also cover the spectrum of
health care payers and providers.
We have software solutions
for care delivery
organizations,
small medical practices
and, provider organizations,
as well as for payer organizations.
So we really have
that entire spectrum within our portfolio.
Fantastic. Well, I appreciate that overview, Angie, and
it sounds like you have a lot of
expertise
in the payer space. So in that vein,
I'd I'd love to ask you about a
trend that leaders in the payer space have
been identifying recently
as both a challenge, but also an opportunity.
And that's the growing trend as you know
of alternative payment models.
So Angie, why is it essential for health
care payers to become more agile in today's
rapidly changing health care environment,
and what are some of the ways that
you think agility can help payers manage their
contracts
more effectively?
You know, alternate payment models have, you know,
been around for
almost 20 years now. Maybe it is or
10 years now, 15 years almost.
They've been increasing
in
use across
health care.
And
not too terribly long ago, it was about
53%
for health care. I think it was, like,
2019, 2020.
53%
of health care organizations
at the facility level, hospital level, community hospitals
had alternate payment models.
There has been kind of in the last
couple years
a trend for
health care to actually go down a bit,
but there is more pressure from outside organizations
like CMS
and other organizations
to actually increase that because
at the end of the day, the the
intent and purpose of value based models is
to increase the value to the patient,
while containing costs in a meaningful way.
We know that our health care model today,
our health care system is less effective
than organizations
in other countries and health care systems in
other countries.
And and I think that was,
talked about by
in on one of your previous podcasts,
doctor Wyatt Decker,
with UnitedHealthcare Group. And he he did a
really good job, I think, of outlining
the challenges in the health care system today
and the things that the industry is doing
to help that. There are different models of
alternate payment contracts
that
focus on different things, but they all focus
on improving value to the patient
and better outcomes with patients.
Because there are so many different models, being
agile is critically important. Different specialties
have different needs, different measures.
Different organization types will have different needs and
different measures. You can't have
the same type of
performance metrics for a primary care practice that
you would for an orthopedic surgeon.
So there's a lot of variety, a lot
of requirements that need to be met for
a
value based contract to actually be effective and
produce the desired results.
Absolutely. That makes complete sense, and I appreciate
you referencing that real world example of that
interview with UnitedHealth Group's, doctor Wyatt Decker, who,
oversees
value based care for for what is a
very large enterprise.
In that vein, Angie, what role do you
think technology
and new tech tools can play in being
more agile and managing
those contracts that we just discussed?
So when it comes to managing contracts, you
know,
there's so many different provisions. Those contracts
are often templated by payers,
but there's provisions in value based contracts that
are very different. Things like, what met what
are the metrics? What are the measures? What
are the obligations of the payer? What are
the obligations of the provider organization,
what do they need to meet. And and
being able to extract that information
from the contract
and apply
the
obligations
of each party
so that they can be managed effectively and
proactively
needs to be met by technology. Because if
you put it in a spreadsheet or expect
to be able to read it out of
a a word document or a PDF document,
you're not gonna effectively manage it and get
the desired outcomes from that.
So using technology is absolutely critical to just
managing the contract itself.
But there's some some interesting things that are
occurring from technology from a standards perspective
With new with the queue HINs and new
API requirements that, CMS published recently that have
to be met
by January
1,
2026
and January 1, 2027,
That will actually increase the capability of interaction
and obtaining information,
aggregating information for both payers and providers,
automated,
prior authorization, and things like that that will
actually
having that technology will make achieving the goals
of the value based contracts
more possible, more feasible, and
require,
to some degree, less manual intervention
to measure
the outcomes of that contract
so that the providers can be properly reimbursed.
And the payers
and providers both will be able to be
more efficient in accommodating and executing against the
terms of the agreement
and achieving better outcomes, not only for individual
patients, but also for full populations.
Understood. So a lot of automation opportunities on
the horizon for payers when it comes to
managing their contracts.
Angie, you mentioned
all the different rules and regulations and policy
changes coming down the pipeline from CMS. It's
a lot for these companies to stay on
top of. So from your perspective,
what would you say are the 3 key
objectives that payers should be aware of right
now, and why?
So I think, you know, emerging standards
have the potential to change that administrative burden.
A lot of physicians, though, don't necessarily have
access
to easily implement technology.
They rely on other practices,
or other organizations
or their software vendors,
to actually help them achieve those organizations
or those those goals and
obligations and standards,
especially when you get out of your large
health care system. So your your hospitals and
your large health care systems,
they generally have full IT departments to do
that, but your smaller practices
have more financial constraints,
on them
to be able to staff and fund those,
especially with
increased inflation and and their margins. You know,
a lot of data shows their margins are
are are reducing, actually.
So
those those changes
cost money from both payers and providers.
Providers are gonna be more constrained in their
ability to do so. So being able to
partner with
partner with other organizations
to help providers achieve that so that it
can be successful
is something to to perhaps consider and evaluate
and understand that providers may not be able
to do that as quickly as payers can.
I think that
payers also are often burdened with aging technology
that is
incredibly complex
and
piecemealed,
not always cohesive throughout the organization.
But some of the,
technology that is being implemented really does cut
across the entire organization.
Having information available,
and and getting modern technology,
modern systems for their core business applications
will help allow them to be more agile.
I think those are some of the key
things that need to be evaluated
by payers when executing and implementing
these technologies and working with the providers
to achieve that as well. Having sufficient and
advanced notice of when changes will be done,
so that providers can keep up.
Absolutely. No. It's it's such great advice that
payers really need to keep the size and
and the capabilities of providers in mind when
implementing
new technologies. And then, of course, internally for
payers, there's a lot of disparate systems that
they're often utilizing, and and new and modern
platforms will help them, stay a lot more
agile as as the landscape evolves.
So looking ahead, Angie, what do you see
as the next big shift in how health
care payers operate, and how should they be
preparing for it?
You know, I think the standards themselves, those
operational standards will have a significant impact
on how they interact with providers. And I
know I said this, and and I feel
perhaps like a little bit of a, you
know, repeat.
But
I I can't really emphasize enough how those
operational standards and having APIs between
the provider and the payer that are more
robust. And with the queue in having more
data that is robust
can change just operationally how they interact with
one another, how they get information that's needed
for a prior authorization, how quick that can
go if the right information is presented at
the right time with having those APIs rather
than
calling into a call center, asking for it,
or going online and submitting a prior authorization
than having a clinical reviewer evaluate it. That
can be done in more real time. Claims
processing can be done more real time, Less
human
interaction and delays
in getting some of those things
completed that require a lot of manpower.
That's not just technological. That's also operational. I'm
looking at the business processes
to achieve that.
And I think that that that's that's part
of what
that big shift is going to be. And
I don't know that we know what that
total impact will be until we start implementing
those changes across
the entire health care industry.
Sure. And it really sounds like everything you
just said, it's focused on efficiency. Efficiency of
those internal processes for payers.
But what else are we missing, Angela? Anything
that we that we didn't get to that
you'd like to touch on, that our listeners
should should really, take notice of?
You know, I think that
I think there's there's broad understanding and acknowledgment
that our health care system is
is not as good as it could be.
And all Americans suffer from that in some
way, shape, or form. It's not just hitting
payers. It's not just hitting, cost of care.
It's not just hitting providers. It's hitting patients
in
having
providers that there's not enough of them. They
don't have enough time because they spend so
much time doing
administrative work. And I'm really excited to see
what
will come out of these changes
and how that will have a significant potential
impact on the quality of care and
the disparity
of
social determinants of health and the disparity of
things like, you know, infant mortality and
maternal death and things like that. How
getting more technology to make providers available to
treat more patients
will have a profound impact potentially on our
entire health care system,
improving the health of all Americans.
Fantastic. Well, Angie, thank you so much for
taking the time to be with us and
for sharing your insights with our listeners. We
truly appreciate it.
Thank you. I enjoyed it.
I'd also like to thank I three Healthcare
Solutions as well for sponsoring this episode. You
can tune in to more podcasts from Becker's
Healthcare by visiting our podcast page at beckershospitalreview.com.