Corporate Insight recently attended Oracle and Fierce Healthcare’s webinar, Navigating New Challenges in Medicare Rx Drug Billing, to obtain an insider perspective on how major healthcare players are adjusting to ongoing development within the Medicare space. Industry experts Kimberly Altman of Optum Rx, Jeff Rivkin of IDC Health Insights and Ajay Ramchandran of Oracle shared captivating insights on the future of Medicare operations and how plan sponsors can ensure they’re keeping pace with the industry. Relatively static in the early 2000s, a steadily expanding aging population and shifted plan liability have created unprecedented change in Medicare. Payers must thus adjust course. Health systems and pharmacy benefit managers (PBMs) are fine-tuning their operations to handle capped consumer payments and subsidies mandated by the Inflation Reduction Act (IRA) while maintaining steady revenue. With this challenge, however, also comes new opportunities to collaborate with external vendors, boost profitability and build upon consumer loyalty within the digital space.

A Shifting Medicare Landscape Spurs Change

This past year presented a myriad of changes related to price transparency and affordability, all sparked by the IRA. With further changes set to begin in 2025, health systems must continue efforts to upgrade their internal systems and user interfaces to comply with federal regulations while maintaining star ratings. Insurers have already adapted interactive user elements to comply with the IRA’s mandates, as shown by the addition of insulin pricing guidelines across quote and enrollment tools within CI’s coverage set. There is still ample work to be done behind the scenes. Experts from the panel discussed several provisions of the prescription law that still require administrator intervention, ranging from educating patients about cost-reducing measures like the Medicare Prescription Payment Program to introducing new software to handle patient subsidies.

BCBS of Massachusetts Public Site Enrollment Application Plan Details Page Select Insulin Section
Anthem BCBS Quote Tool Insulin Coverage Section

New strategies must be developed to address compliance regulation, while the surge in Medicare prescription services also poses a significant challenge. Data from CI’s Healthcare Consumer Survey Analysis shows prescription benefits rank as the most applied Medicare benefit, as indicated by 87% of respondents, outranking both provider visits and laboratory services. With such high usage, payers and their partners must develop new strategies to optimize patient care and operational efficiency.

Benefits used by Medicare beneficiaries within the last 12 months according to Corporate Insight’s 2023 Healthcare Consumer Survey Analysis

Industry Perspectives

Panelists took varying approaches to addressing this issue. In response to the ever-growing aging population, Ajay Ramchandran of Oracle focused on the preventive approach, urging insurers to bolster investments into programs that reduce the occurrence of chronic diseases. Fifty-five million individuals within the U.S. are eligible for Medicare as this population continues to expand, creating an ecosystem that minimizes preventable diseases could preemptively eliminate significant prescription costs. Ramchandran also explored the explosion of home-based care, delving into the benefits of telehealth and wearable devices, particularly for rurally based patients that have limited access to care.

Jeff Rivkin of IDC Health Insights supported this perspective, calling for a holistic care approach that leverages patient education initiatives to boost member engagement among the growing geriatric care population. Deepening care management with tools such as symptoms checkers and improved enrollment experiences creates a basis of patient involvement that often leads to better health outcomes, thereby diminishing the financial responsibility of payers. CI’s most recent Medicare Unique and Innovative Features report examines the rise of interactive educational tools, spotlighting exemplary industry chat tools and microsites that enhance the user experience.

BCBS of Texas My Medicare Timeline Tool Page

Notably, Rivkin endorses acquiring data from external partnerships. He promotes the use of competitive benchmarking, data sets that evaluate and compare individual firm capabilities across the industry, as these provide best-in-class examples of digital user interfaces among competitors. Further, obtaining population analysis on social determinants of health could serve to help tailor marketing and benefits towards specific demographics while facilitating compliance. As CMS continues to establish policy that advances health equity, such data would be an invaluable long-term investment for payers intent on adapting to the evolving Medicare landscape.

“Data is king, it’s the commerce of payers.”

– Jeff Rivkin

For more insights into digital innovation in the healthcare space, check out our research services in four areas: Health PlanMedicareHealth System and Pharmacy. For deep dives into specific topics, check out our Healthcare Briefings. Don’t forget to visit our Insights section for more industry trends and best practices across the healthcare industry.