What You Should Know:

• Pair Team, a virtual and community-based primary care solution connecting Medicaid’s highest-risk patients to high-quality care, today announced it has raised $9 million in Series A funding. The financing was led by NEXT VENTURES, with participation from PTX Capital, Kapor Capital, Kleiner Perkins, Y Combinator, and several notable healthcare angel investors including Jay Desai.
• The funding will be used to help Pair Team accelerate its expansion across California by enabling the company to grow its network of safety net organizations and scale its current team to support additional patients.

Funding to Accelerate Expansion of Large-Scale Safety Net Organisations 

With nearly $10B in total funding, California Advancing and Innovating Medi-Cal (CalAIM) is integrating social support services such as housing, food access and transportation through local health plans for low-income residents. The goal is to elevate the role of community-based organizations (CBOs) such as shelters, food pantries, and rehab facilities in the care delivery system. This is the future of Medicaid laid out by CMS, and other states like New York are following suit. However, local clinics and CBOs lack the resources to effectively coordinate and establish a new model of care.

Pair Team solves these issues by partnering with local health centers and community-based organizations, giving them access to a shared, value-based care management platform that is utilized by Pair Team’s network of safety net organizations and providing staffing support to fill gaps in care access and coordination. By enabling existing organizations to provide both virtual and in-person care through its shared platform, Pair Team connects Medicaid’s highest-risk patients with the information and services they need, such as housing coordination, grocery delivery, medication management, virtual therapy and other primary care services.

“Pair Team’s hands-on approach is changing lives for thousands of Californians who are not able to access the care needed to better their health. Our virtual and community-based solution builds personal and meaningful relationships with our patients to help them regain trust in and access to the health care system,” said Neil Batlivala, CEO and co-founder of Pair Team. “This latest financing will help us bring whole-person care to more patients across California, and soon nationally. This is Medicaid’s regulatory moment, and we are here to help catalyze much-needed change for the wellbeing of our most vulnerable communities.”

What You Should Know: 

– Waymark, a San Francisco, CA-based Medicaid provider enablement company raises $42M in new financing to scale technology-enabled, community-based care for primary care providers and their patients enrolled in Medicaid programs. The round was led by Lux Capital and CVS Health Ventures joins as a new investor. 

– Existing investors Andreessen Horowitz (a16z) and New Enterprise Associates (NEA) also participated in the round. The investment consists of $22M in equity capital and a $20M line of credit, bringing Waymark’s total capital raised to date to $87M.

– Waymark plans to use its new investment to continue improving healthcare access and outcomes for people enrolled in Medicaid programs. 

Better Care Starts with Community

Patients receiving Medicaid benefits often experience challenges accessing care, prescriptions, and social support like housing and food. Waymark hires, trains, and deploys local teams of community health workers, pharmacists, therapists and care coordinators to work directly with primary care practices – at no cost to the practice – and address gaps in care for their patients enrolled in Medicaid. The company’s local teams are supported by Waymark Signal™, a proprietary machine learning technology that has shown industry-leading performance in identifying “rising risk” populations, or patients at risk of avoidable emergency room (ER) and hospital utilization, and helps to direct Waymark teams to the best evidence-based intervention to meet patient goals. The technology is integrated into a care management software built by Waymark specifically for community-based teams, and incorporates data from multiple sources (e.g., local ERs, primary care practices, social services databases, and health plan data) to engage patients who are traditionally hard to reach.

Waymark enters into risk-based contracts with Medicaid MCOs to deliver community-based care for their rising risk populations and transition primary care practices to value-based arrangements. By building a new community health workforce to support primary care providers (PCPs) – paid for through value-based arrangements with MCOs – Waymark seeks to increase the capacity of its healthcare delivery system and align payment incentives to enable whole-person care.

Market Footprint

Waymark is currently supporting approximately 50,000 people enrolled in Medicaid across both Washington state and Virginia. Since launching in January 2023, the company has secured partnerships with several large health systems, a federally qualified health center (FQHC), and independent practices across both markets. Through its evidence-based care pathways, Waymark has shown promising early improvements in quality scores and clinical outcomes – including reduced non-emergent emergency department (ED) visits and hospitalizations.

“We created Waymark because the evidence of what works to improve Medicaid outcomes exists, but the operational capacity, technology and funding is insufficient to scale to the level of need that exists in communities across the country,” said Dr. Rajaie Batniji, co-founder and CEO of Waymark. “This new financing will allow us to continue hiring and training a new community health workforce, expand PCP capacity, and ultimately deliver on our charter to improve access and quality of care for people receiving Medicaid.”

As a result of the Families First Coronavirus Response Act (FFCRA), Medicaid programs were required to keep citizens continuously enrolled through the COVID-19 public health emergency (PHE). These continuous enrollments ended on March 31, 2023, resulting in what many call the unwinding of Medicaid. 

In June, the Kaiser Family Foundation (KFF) estimated that between 8 million and 24 million people will lose Medicaid coverage during the unwinding of the continuous enrollment provision. The unwinding of Medicaid has become one of the most significant challenges facing state health agencies. 

The Medicaid redetermination process has become mired in procedural challenges during the renewal process, resulting in CMS pausing Medicaid redeterminations in six states. 

In August, CMS also sent a letter to Medicaid directors in all 50 states that evaluated performance on Medicaid call center wait times, call abandonment rates, rates of procedural terminations, and average wait times for applications to be approved. Overall CMS found that 36 states were falling short on meeting the regularity requirements. 

State and local HHS agencies are clearly in the midst of a public health emergency and are finding themselves challenged with processing Medicaid redeterminations at record levels as they resume regular eligibility operations following the end of the Medicaid continuous enrollment condition. 

In addition, many of these agencies are dealing with eligibility and enrollment systems that have been in place for 10 years, or even longer. As a result, these systems are hitting “legacy” classification, and lack modern features to keep up with the current Medicaid redeterminations challenge. 

With the immense ebb and flow of eligibility applications and redeterminations, it is clear that data is key to overcoming this challenge. On top of this, an astounding level of data is increasing every day, along with the demand to leverage this data to meet citizens’ needs.

Automating Legacy Systems 

Fortunately, state health agencies can address these challenges by automating legacy data systems without needing to invest in full IT modernization. 

Legacy systems are essentially mission-critical systems that contain custom code and business processes designed to serve citizens. Part of the challenge is the lack of automation to deal with high volumes of eligibility redeterminations and disenrollments while ensuring coverage continuity for eligible members.

It is possible to create a path to accessing and engaging with data on legacy systems to break down data silos while enhancing overall processes. By combining these modernizing citizen-focused interfaces, agencies can streamline the Medicaid reenrollments, while reducing errors. 

For example, process mining can help agencies pinpoint processes for improvement and allow simulation of the new processes. These types of solutions can run on top of an eligibility and enrollment existing process engine, providing insights into bottlenecks or outliers.

These solutions also offer easy-to-use interfaces that can help business analysts visualize areas of improvement. New processes can also be simulated before going into production for testing desired outcomes and adjusting as necessary.

Many states are also exploring moving their eligibility and enrollment systems to the cloud, which offers new ways to integrate data more effectively to meet citizen needs.  

This transition can be made seamlessly by quickly integrating applications in the cloud, while also offering end-to-end monitoring to follow the complete flow of transactions across multiple applications. As a result, users can easily visualize integration processes and simulate to-be scenarios to assess impact. 

Regardless of the complexity of the data, common integration scenario templates can provide a quick start to integration development. In addition, key solutions allow agencies to pull data from any source across the HHS landscape, which can include data warehouses or legacy mainframes into one common picture. 

By providing an updated visual interface through a range of pre-built connectors, agencies can easily ingest, transform, and deliver data to the desired destinations. This enables them to detect patterns, anomalies, and trends in real time, which can be used for predictive analytics or immediate decision-making around the redeterminations issue. 

The unwinding of Medicaid is presenting a significant challenge for states, as well as for citizens who have relied on receiving this critical healthcare coverage.  Fortunately, updating the manner in which we engage with legacy systems, and better leveraging the data housed in those legacy systems, provides a path for agencies to ensure that citizens don’t lose coverage due to administrative and procedural issues. 

About Chris Oskuie

Chris Oskuie is the Vice President, State & Local Government and Education Sales at Software AG Government Solutions.  Chris has more than 20 years of experience working with Federal and State Government programs. For the past four years, Chris has led a team of experts that helps government agencies modernize how citizens and state employees engage with and access legacy systems through data and event-based integration.

During the pandemic, Medicaid enrollment grew by nearly 30% to cover more than 93 million Americans, due in large part to COVID-19 provisions that included continuous Medicaid enrollment. With the unwinding of these pandemic emergency orders, annual cycles of Medicaid redetermination have returned. As a result, states have removed close to 4 million Americans from Medicaid to date. The ongoing redetermination process is likely to expand health inequities across the nation, including in California.

For our most vulnerable communities, Medicaid is a lifeline to care. Medicaid delivers health care, behavioral health, social services, and other necessary resources, by which health care organizers, providers, and community entities partner to deliver better outcomes for enrollees.

The process of redetermination, which relies on the accuracy of demographic data including mailing address and phone numbers, is a prime example of why data collection and management needs to be coordinated responsibly to best improve health at the individual and population levels; within this HIT plays an essential role. In recognition of the procedural burden our existing processes and systems exact, Health and Human Services Secretary Xavier Becerra has encouraged states to use all available strategies to streamline redeterminations and prevent eligible enrollees from losing coverage due to procedural issues. 

Shared health data is the connective tissue that brings together patient medical histories with other social determinants of health (SDoH) data, but it must be the right kind of data: That which reflects whole person care and embraces a co-designed approach to deliver high-quality outcomes. 

Use Data to Advance Access, Not Erect Barriers 

There is an enormous opportunity within the healthcare and social services ecosystem to be more mindful and intentional with data collecting. This can be advanced through better coordination between community-based organizations (also known as CBOs), advocacy groups, and individuals with lived experiences who can share best practices aligned with community needs and preferences. It is also critical to be mindful of where gaps may be occurring, such as the challenges of collecting information, for instance, on the more than 160,000 Californians facing homelessness.

It’s also critical to consider who needs access to this information and how it is used. Data collection and sharing should be used to help providers deliver care more effectively and efficiently; it shouldn’t put individuals at risk of not receiving essential care and services. Sharing health information can feel particularly risky to some populations that have been or still are the target of discriminatory actions and policies, including Black Americans, those seeking abortion services, individuals that identify as LGBTQ+, and minority religions.

Why We Need Whole Person Care

Whole person care is a proactive, modern approach in which health is viewed holistically. It considers not only health information, but also behavioral health and SDoH. A more comprehensive understanding of the connections between genetics, environment, access to nourishing foods, wellness and disease also helps impact health through the influence of behaviors, environments, and policies. In this approach, patients and doctors share decision-making and benefit from a variety of care delivery methods, such as virtual appointments, community resources and in-home care. 

There is already momentum at the federal level to prioritize whole person care. We are seeing a growing number of policies and regulations aimed at improving services for historically overlooked communities, including Section 1115 Medicaid waivers that expand coverage and reduce health disparities. In California, whole person care is a central component of the transformation of Medi-Cal through CalAIM, which is focused on delivering to the state’s 15.3 million Medi-Cal members a more equitable, coordinated, and person-centered approach to positively influence their health and life trajectory. 

Co-Designed Solutions for Better Health and Wellbeing 

In the context of redetermination, sharing data across healthcare and social services allows providers to have the latest, most accurate health data and contact information on Medicaid enrollees so they can properly support them throughout the redetermination process. Maryland is already using its state’s health data utility to prevent gaps in care. Additional partnerships with managed care plans, CBOs, and shared data from the United States Postal Service to update contact information also helps. 

Delivering equal access to information creates a stronger system that prevents high-risk individuals from falling through the cracks. This equality supports stronger alliances between health plans, hospitals and health systems, providers and social needs intermediaries, such as community health workers, CBOs, peer support specialists and behavioral health experts who can serve as navigators between health and social services.

Within co-designed solutions, health plans support access to care and resources by building trust and working closely with providers, the community, and others on the frontlines. It shifts the focus from tracking down and verifying information to collaborating on which care levers most effectively lead to the best outcomes.

A Brighter, More Equitable Future is Ahead

The health care system relies on accurate data and information to provide essential care for our country’s most vulnerable populations, and no example is more clear than in our Medicaid redetermination cycles. If data is inaccurate, outdated, or inaccessible, individuals will become ineligible.

Beyond eligibility, inaccurate information has the power to negatively affect the quality of care received across the healthcare and social services landscape.

We have an exciting opportunity—and urgency—to create more inclusive processes and systems, powered in part by HIT, that recognize and advance health equity within populations while implementing insights based on existing data. It’s time for all of us involved in healthcare to recognize our role and responsibility to use all data, past and future, for good. 

About Adimika Arthur

Adimika Arthur is the CEO and Executive Director of HealthTech for Medicaid (HT4M). She is a visionary and strategic executive who has spent over two decades in healthcare and whose research experience in health equity, investments and disruptive technologies provides companies insights while competing in a rapidly shifting market. 

About Manisha Sharma, MD, FAAFP

Manisha Sharma, MD, FAAFP is the Senior Medical Director, Promise Health Plan at Blue Shield of California. Sharma is a board-certified family medicine physician who works at the juncture of patient care, community health, social justice, health policy, and innovation. She is committed to “being the change” in how healthcare is delivered in the United States.

What You Should Know:

• A new report released by TytoCare, a virtual care company enabling accessible, high-quality primary care from home, revealed insights into how health plans and organizations can drive virtual care engagement.
• While key elements that patients value in virtual care offerings include cost and time savings, and the ability to reduce Emergency Department (ED) or urgent care visits, people want to see doctors they trust or and are more likely to adopt virtual care when recommended by their primary care physicians (PCPs).

Understanding and Improving Virtual Care Engagement

TytoCare, a virtual care company, has released a report on how health plans and organizations can increase virtual care engagement. The report is based on a survey of more than 1,000 Medicaid and commercial health plan members in the United States. Key findings include:

• 78% of respondents consider virtual healthcare offerings to be an important factor when selecting a healthcare plan.
• Time and cost savings are the top drivers for virtual healthcare adoption.
• A healthcare provider is more likely to influence the use of virtual care than a family member or an insurer.
• Clinician involvement is critical for both Medicaid and private insurance carriers.
• 90% are willing to forfeit the wait for their PCP to get quicker access to care in a crisis.

TytoCare’s Home Smart Clinic is a solution that combines their handheld remote examination device, AI-backed smart diagnosis support, and Tyto Engagement Labs to provide high-quality, accessible virtual care in the home.

The survey also found that 73% of respondents who utilized virtual care did so two or more times per year, with 46% using it three or more times. Additionally, 81.4% reported that they would be interested in using virtual care programs if they had access to specific devices that offered features above and beyond video calls.

In summary, patients value cost and time savings in virtual care offerings, but they are more likely to adopt virtual care when recommended by their primary care physicians. Clinician involvement is critical, and recommendations from family members or friends are less effective in motivating people to adopt virtual care. TytoCare’s Home Smart Clinic is a solution that drives engagement rates in virtual care by providing high-quality, accessible virtual care in the home.

As the healthcare industry continues to evolve, there is a growing need for innovative solutions that not only improve the quality of care but also make care more accessible. Non-emergency medical transportation (NEMT) plays a crucial role in helping patients get to where care is delivered. As healthcare reform efforts continue to gain momentum, transportation benefits have become an increasingly critical component of providing equitable care to patients. NEMT helps close the health equity gap by ensuring all patients can access care, regardless of their location, medical needs or transportation options.

In recent years, technology has played a significant role in the advancement of the NEMT industry. Modern NEMT solutions streamline the ride booking and scheduling process, introduce new modalities, improve the overall experience for patients, and decrease fraud, waste and abuse (FWA). For decades, the industry lacked a patient-centric approach focused on efficiency, reliability, and accessibility for all populations, especially those enrolled in Medicare Advantage and Medicaid plans.

A reliable NEMT program can help health plans reduce administrative burden, lower the number of missed appointments, and ensure that patients receive the right level of care and support at the right time during their healthcare journey. Using integration services, health plans can integrate NEMT solutions and programs directly into existing platforms to better manage the member experience and provide an extra layer of connection for members when they utilize these benefits.  

By collaborating with innovative NEMT partners, health plans have made great strides to enhance the overall member experience. Historically, the member journey was largely overlooked, limiting members to two-day-plus advanced notice or long wait times for rides. With the introduction of on-demand ride-booking services through rideshare partners like Uber and Lyft, member needs are prioritized and personalized. Patients can book a ride when and where they need it; then, plans receive real-time updates and notifications during a member’s ride and can make any necessary adjustments as needed. Real-time ride monitoring helps reduce stress and anxiety for patients, prevents FWA, and ensures every ride has a digital record complete with geolocation at every step of the journey.  

While technology-first NEMT has advanced rapidly over the past few years, we’ve only begun to scratch the surface of how it can revolutionize care accessibility. As Medicare Advantage and Medicaid plans continue to grow, NEMT partners will play an increasingly important role in scaling transportation benefits. By working with healthcare providers and payers to integrate NEMT benefits into existing programs and systems, we can provide high-quality transportation services to our most vulnerable populations.

Given the proximity to high-acuity and underserved patients, who are commonly enrolled in Medicare Advantage and Medicaid plans, it’s important to determine whether a transportation provider has the capacity and expertise to meet the individual needs of each member. In a recent study, 21% of U.S. adults without access to a vehicle or public transportation skipped needed medical care last year. This experience is shown to vary depending on other factors such as race and ethnicity, household income, urban or rural location, disability status, and more. Expanding ride modalities with options like on-demand rides provides members the flexibility and comfort they’re looking for in an increasingly-consumer driven healthcare environment as well as plans with the tools they need to close these health equity gaps in accessing care for a diverse population. 

By offering members benefits that work for them and their unique needs, plans can focus on increasing benefit utilization and improving critical present and future Stars Ratings benchmarks like member experience and health equity. When measuring a program’s effectiveness, vendors and plans must work together to decide which data to capture, determine what’s working, and identify areas for improvement. Technology-first NEMT plays a critical role in capturing data and turning it into metrics that matter. 

Despite great strides made to help address the social determinants of health (SDoH), such as transportation access, government regulations continue to play a critical role in shaping the industry’s growth and impact. Various regulations, such as the Medicaid Non-Emergency Medical Transportation Benefit and the Americans with Disabilities Act, have positively impacted how patients access care and the quality of transportation services provided by NEMT vendors. These regulations are crucial for individuals who may not have reliable transportation options, especially those living in rural or low-income areas, and help ensure NEMT providers meet specific quality standards and are held accountable for providing safe and dependable transportation services. As the NEMT industry continues to evolve, it is important for providers to stay informed about the latest regulations and to work closely with government agencies to ensure they are providing the highest quality transportation services possible. By doing so, they can help close the healthcare equity gap and ensure all patients have access to the care they need.

While we can’t predict all the roadblocks the healthcare industry will face in the future, it’s clear that a more efficient, reliable and cost-effective NEMT solution will continue to drive better outcomes for health plans and patients. 

About Andy Auerbach

Andy Auerbach is the Chief Revenue Officer of SafeRide Health, the leading technology-first platform connecting patients to care one ride at a time.

What You Should Know:

• A new analysis shows more than 21% of U.S. adults without access to a vehicle or public transit went without needed medical care last year. These individuals were significantly more likely to skip care than those who reported neighborhood access to public transit services (9%).
• This analysis examining the association between transportation and access to healthcare was conducted by Urban Institute researchers with support from the Robert Wood Johnson Foundation. 

Analysing and Addressing Barriers to Healthcare

Research shows that public transportation expansions improve access to health care, especially for people covered by Medicaid.

Using June 2022 data from the Urban Institute’s Health Reform Monitoring Survey (HRMS), it was identified that there exists a link between transportation barriers to healthcare and the association between public transit accessibility and access to care. Focusing on adults without access to a privately owned vehicle, key findings identified are as follows:

• Approximately 5 percent of non-elderly adults did not get needed health care in the past 12 months because of difficulty finding transportation, and this experience was more common among adults with low family incomes (i.e., below 138 percent of the federal poverty level [FPL]), adults with disabilities, adults with public health insurance coverage, and adults without household access to a vehicle.

• While 91 percent of adults reported having household access to a vehicle, this figure was substantially lower among Black adults, adults with low family incomes, adults with a disability, and adults with public health insurance or no health insurance coverage.

• Adults without access to a vehicle who reported living in neighbourhoods with fair or poor access to public transit were significantly more likely to forgo needed health care because of difficulty finding transportation compared with their counterparts reporting excellent, very good, or good neighbourhood access to public transit.

• City-level transit scores from WalkScore.com, based on distance to transit stops and frequency of transit service, were less predictive of access to health care than self-reported measures of neighbourhood public transportation access.

Among the share of adults who did not get needed healthcare in the past 12 months because of difficulty finding transportation, responses varied significantly by demographic and socioeconomic characteristics.  Specifically, not getting needed health care because of difficulty finding transportation was significantly less likely among adults with the following characteristics:

• White adults and Asian adults compared with Black and Hispanic/Latinx adults.

• Adults who have family incomes between 139 and 399 percent of FPL or 400 percent of FPL or more compared with adults who have incomes at or below 138 percent of FPL.

• Adults who do not have a disability compared with adults who have a disability. 
• Adults who have private insurance compared with adults who have public insurance or no insurance.

• Adults living in an urban area compared with adults living in a rural area.

• Adults who have household access to a vehicle compared with adults who do not have access to a vehicle.

Additionally, it was also identified that demographic and socioeconomic differences in household access to vehicles follow similar patterns as unmet health care needs because of transportation barriers. Further details revealed that:

• 91 percent of adults reported having household access to a vehicle.

• Black adults were significantly less likely to have access to a vehicle than Hispanic/Latinx adults, white adults, Asian adults, or adults of other races.

• Adults with family incomes at or below 138 percent of FPL were significantly less likely to have access to a vehicle than adults with family incomes between 139 and 399 percent of FPL or 400 percent of FPL or more.

Lastly, among adults without a vehicle, self-reported fair or poor public transportation accessibility is strongly associated with not getting needed health care because of difficulty finding transportation, even after adjusting for other demographic, socioeconomic, and geographic characteristics, specifically race/ethnicity, family income, disability status, health insurance coverage, rurality, population density, and major metropolitan area of residence:

• 22 percent of adults reporting the ability to get around without driving in their neighbourhood is fair or poor did not get needed health care, compared with only 9 percent of adults who reported excellent, very good, or good ability to get around without driving.

• Similarly, 21 percent of adults reporting fair or poor access to public transportation had this experience compared with only 9 percent of adults who reported excellent, very good, or good access to transportation.

What You Should Know:

– The National Committee for Quality Assurance (NCQA) today launched the Race and Ethnicity Stratification Learning Network, a free, interactive, online tool that offers data and best practices to help health plans improve how they collect race and ethnicity data on their enrollees. Improving data collection of race and ethnicity data is vital to improving health equity.

– The data available in this new resource summarize the care of 20 million people enrolled in 14 health plans that reported results on 5 HEDIS measures, stratified by race and ethnicity. Best practices on the site come from NCQA’s qualitative interviews of key staff at the 14 plans that compose the learning network.

About the Race and Ethnicity Stratification Learning Network

The Race and Ethnicity Stratification Learning Network was convened in late-2022 to develop a greater understanding and resources to support the stratification of quality performance data and use of stratified data to advance health equity.

Learning Network findings reflect 101 contracts across Commercial (27%), Medicaid (41%), Medicare (24%), and Exchange (9%) product lines, representing over 19 million covered lives. One participating organization could contribute multiple contracts. Each contract was assigned to a geographic region. Data submissions reflect a measurement period of January 1, 2021, through December 31, 2021.

Each participating organization was asked to identify key stakeholders to participate in the interview process. The final list of participants represented a range of roles, including data analytics, quality improvement, accreditation, quality management and improvement.

The prevailing global economic conditions are negatively impacting the healthcare industry. Continuing staff shortages, endemic COVID-19, high inflation rates, and supply chain disruptions continue to drive medical costs higher, worsening what is already a persistent challenge for health insurers. 

To offset rising healthcare costs, health insurance payors are challenged to find ways to contain their own costs by streamlining their processes and tightening their belts, which invariably sees their handling of unstructured data come under increased scrutiny.

Health insurance payors handle large volumes of unstructured data from healthcare providers, vendors, policyholders, and others as part of the revenue management cycle. These unstructured documents, many of which are handwritten, require manual processing and data extraction, which is extremely time-consuming and dramatically increases administrative costs. 

In a largely paper-bound industry like healthcare, automated intelligent document processing opens up multiple opportunities for cost savings through streamlined workflows.

 Below are six common ways in which health payors can use intelligent document processing to rein in medical costs, make their internal processes more efficient, and uncover deeper data-driven insights.

1. Appeals and Denials

Providers can appeal a payor’s decision to deny payment for a submitted claim – demonstrating why the claim should in fact have been paid. These appeals are typically emailed to payors along with a variety of forms and attachments, some of which may be handwritten, as proof of the medical need. 

The unstructured documents involved in the appeals process are highly variable and typically handled via manual processing and review. The time involved in manual reviews in turn delays appeal decisions, potentially damaging payor/provider relationships. At the same time, the labor costs involved are high as payors may have a backlog of tens of thousands of appeals in process at any point in time.

Intelligent document processing leverages deep learning technology to ingest, classify, and extract relevant data from these highly variable documents that we know as unstructured data. By automating what was once a tedious, time-intensive process, intelligent document processing shortens the appeals cycle, which reduces operational costs and facilitates better payor/provider relationships.

2.Prior Authorizations

Some insurers require preauthorization for specific types of care. A prior authorization is a directive or request from a medical professional to preapprove a prescription or certain type of procedure or treatment for an insured patient. 

Prior authorization requests are typically sent via fax or physical mail. They often include handwritten notes from providers, patient medical histories, clinical notes, and other highly variable documents. As with appeals, prior authorizations are often manually processed because of the variability and unstructured nature of the documents provided.

Intelligent automation uses deep learning to pull critical data from this unstructured data, organize it, evaluate it, and learn patterns from it. As document processing accuracy and speed increase, the time from initial request to authorization is reduced, which helps patients get the care they need faster and reduces operational costs for the payor.

3.Provider Onboarding

Onboarding a new provider and or his or her practice into an insurance network and creating a profile for inclusion in member network directories involves a lot of unstructured data. The information supplied by the provider and the practice or facility, will include the provider’s name, address, and other contact details which of course vary greatly from other providers’ applications and so require manual processing. Ideally, onboarding should be a seamless process, so that providers’ profiles become accessible to patients within the insurer’s network as quickly as possible.

Today, the process can be automated. Intelligent processing expedites the timeline for registration completion and improves the accuracy of provider information in network databases and directories.

4. Medical Claims

While a medical claim is one of the most basic documents in the insurance process, manual processing makes the processing thereof anything but basic. Claims can come in the form of invoices, letters, handwritten notes, and other highly variable document formats. Manual processing lengthens the claims cycle and slows payout times to providers or patients.

Intelligent processing on the other hand speeds up the timeline for claims review and improves accuracy in correctly matching procedure coding with covered services. Accurate claims decisions limit the number of legitimate appeals that payors have to process.

5. Commercial Risk Adjustment

One of the most critical areas for intelligent document processing is commercial risk adjustment. This process takes place in Medicare, where the payor is the administrator of plans that are paid by the U.S. Government through CMS. Medicaid and Medicare account for 36.5% of the U.S. health insurance market.

Payors receive medical records from providers of all services. The payor then adjusts and pays the claim before requesting reimbursement from CMS. Each service is coded with standard medical coding, such as ICD-10 codes, which the payor uses to determine whether a diagnosis or procedure is covered by the subscriber’s plan. Accuracy in records reviews is essential to determine how much money the insurer is likely to get back from CMS. Errors can lead to either over- or under-payment by the payor.

Intelligent document processing increases the accuracy of records reviews and speeds up the process, decreasing the time between when the payor pays claims and when they in turn receive reimbursement from CMS.

 6. COVID Certification

COVID vaccination cards are a good example of how new or variable document processing occurs over time, in addition to the conventional document processing already described, . These cards are usually handwritten and typically require a manual review. However, with intelligent processing, they are faster to process, and data is extracted more accurately.

At some point, COVID certifications will probably become obsolete. However, other limited duration documents like this come around periodically in the insurance sector, adding to the enduring document types already described. Manual reviews on these short-duration documents are especially challenging given that there are no long-established protocols for them. Deep learning technology allows for rapid learning for efficient document processing.

Fast and accurate insurance document processing helps the overall health system to cut costs, ensure timely treatment for patients, and spend less time handing appeals and service calls. Plus, there is the improved reputation that ensues for insurers in the provider network among subscribers. 

About Tom McCann

Tom McCann is the Growth Strategy & Business Development at Instabase, a San Francisco-based startup that created the created the first automation platform for unstructured data, enabling organisations to drive transformation across manual processes by unlocking unstructured data with deep learning.

What You Should Know:

• Glytec, the only provider of cloud-based insulin management software across the continuum of care, today announced the next evolution of GlucoMetricsⓇ to provide new analytics, dashboards and data visualizations that give hospitals and health systems new insight into glycemic outcomes. The enhanced visibility this provides is essential as hospitals prepare for new measures from the Centers for Medicare and Medicaid Services (CMS) on severe hypoglycemia and hyperglycemia that encourage facilities to report metrics starting in early 2024.
• GlucoMetrics is powered by data from Glytec’s eGlycemic Management System® (eGMS). Centered on Glucommander,Ⓡ eGMS is an EHR-integrated, HITRUST certified, cloud-based software solution that supports personalized insulin dosing decision support at the point of care. Providers and nurses who use Glucommander help their patients get into target range faster, stay within tighter parameters and experience fewer insulin-related adverse drug events than patients treated with other protocols.
• With significant enhancements to GlucoMetrics, glycemic management committees and hospital leaders now have self-serve access to key performance indicators, trends, and benchmarks related to glycemia treatment across their entire health system. GlucoMetrics is pre-configured with six interactive dashboards to help surface insights at both a macro and micro level. 
• These dashboards include powerful filters to segment data by time frame, facility, unit, treatment type (IV or subcutaneous) and more, to provide granular details across an entire healthcare system or down to an individual hospital unit level. Users can also customize their experience with saved views and personalized email subscriptions. In addition, they can easily export charts, tables, graphs, and data to Microsoft Excel or PowerPoint for even more sophisticated analysis, further annotations, or distribution.

What You Should Know:

• 1upHealth, a modern data platform that’s cloud-based, API-enabled, and FHIR-native today announced the close of a $40M Series C investment led by Sixth Street Growth with participation from existing investors F-Prime Capital, Jackson Square Ventures, and Eniac Ventures. 
• Founded in 2017, 1upHealth’s FHIR®-native platform designed for interoperability and modern computing is used by over 75 enterprise organizations including leading national and regional health plans, the highest performing CMS ACOs, international clinical research organizations, and over 20 state Medicaid agencies. By leveraging the industry’s FHIR standard, modern and open cloud architecture, and restful APIs, 1upHealth helps customers acquire, store, and interact with the data needed to power their business operations and analytics.  

Expansion Plans

1upHeath plans to use the latest round of funding to accelerate efforts in building the 1upHeath Data Cloud across three key areas:

1. Invest in product development and engineering in preparedness for proposed and future CMS regulations
2. Enhance 1upHealth data cloud infrastructure for serverless scalability and open access
3. Grow Customer and Services teams to support market expansion across payers, providers, pharma, digital health and more

What You Should Know:

Audio-only telehealth visits for both primary care and mental health services remained common at safety net clinics in California since the start of the COVID-19 pandemic, according to a new RAND Corporation study.

The RAND study published in the Journal of the American Medical Association found that in August 2022 audio-only visits still accounted for 1 in 5 primary care visits and 2 in 5 behavioral health visits among people who received care at Federally Qualified Health Centers in California.

Researchers say the higher rates of audio-only telehealth in safety net settings raises questions about the quality of care and equity for low-income patients, since the effectiveness of audio-only telehealth has not been established.

Key findings of the report include:

• The number of primary care visits increased by 8.5% from February 2020 to August 2022, while the number of total behavioral visits increased 23% during the same period. The increases are likely the result of being able to widely offer telehealth services, even as the clinics lost staff members.

• audio-only telehealth visits for primary care services peaked in April 2020, while audio-only visits for behavioral health peaked in March 2021.

• Within primary care, the decline in audio-only visits from the early pandemic peak appears to coincide with the return of in-person visits rather than growth in video visits.

• For primary care, the proportion of in-person visits increased from 30% in April 2020 to 71% by August of 2022.  Over the same period, audio-only visits decreased from 67% to 21%, while video visits increased from 4% to 7%.

• For behavioral health, the proportion of in-person visits increased from 20% in April 2020 to 37% in August 2022. During that period, audio-only visits for behavioral health care decreased from 74% to 39%, while video visits increased from 8% to 23%.  

• Federally Qualified Health Centers’ continued use of audio-only telehealth may be a result of the clinics and their patients not having access to the technology needed for video telehealth. In addition, since California’s Medicaid program (Medi-Cal) granted permanent payment parity for audio-only visits, there are no financial incentives for the clinics to limit audio-only visits.

What You Should Know:

• 2023 started off with the hallmarks of a rebound year. While Q4 2022 signaled the tail end of the digital health funding cycle, January and February funding numbers began to suggest that sector investment was slowly but surely inching back upwards. Inflation was easing ever so slightly. Investors were rediscovering their confidence and launching new projects, signaling optimism in the sector, according to a new Rock Health report.
• However, recent news—the collapse of Silicon Valley Bank, the seizure of Signature Bank, Moody’s downgrading of bank credit ratings, and another Fed rate hike—was a stark reminder that the choppy waters of 2022 aren’t over yet. 

Key Trends and Insights from Q1 2023 – Digital Health Funding

There’s no denying that Q1 2023’s economic conditions, bank scares, and regulatory changes have digital health startups of all sizes nervous, whether they’re trying to raise their next funding round or waiting for the right time to exit.

The following key trends from Rock Health’s report are a review of the venture, banking, and policy waves breaking within digital health, coupled with insights regarding the volatility of the modern-day regulatory landscape, how the financial market seems different for everyone, and how small-scale startups have it the hardest.

Q1 Funding Soars, But 2023 May Struggle to Catch Up to 2019

Q1 2023 U.S. digital health funding closed with $3.4B across 132 deals, with an average deal size of $25.9M. While this quarter exceeded both Q4 2022’s $2.7B and Q3 2022’s $2.2B funding pots, Q1 isn’t enough to signal a new “bull run.” If funding for the next three quarters matches the average funding across the prior three quarters, 2023 is on pace for the lowest level of annual funding since 2019. The truth remains that the founder-friendly market of 2021 and early 2022 has tilted sharply toward investors.

Notably, within its $3.4B raised, Q1 2023 saw heavy representation of mega deals. After only six digital health raises over $100M across Q3 and Q4 2022 combined, Q1 2023 logged six megadeals from Monogram Health ($375M), ShiftKey ($300M), Paradigm ($203M), ShiftMed ($200M), Gravie ($179M) and Vytalize Health ($100M)—accounting for 40% of the quarter’s total digital health funding.

Silicon Valley Bank’s Collapse

SVB’s collapse nearly precipitated a liquidity crisis in the sector, and concerns circulated that startups might need to engage in distressed debt buys or raise emergency bridges—possibly with “lender-friendly” terms or at slashed valuations—in order to secure working capital. It’s worth pointing out that not all digital health startups carried the risk burden equally. Startups with well-established investors were more likely to have the assurances of cash floats and level-headed perspectives from advisors who have been around the block a few times, while those with greener syndicates were left unsure of whether their own funders could even weather the storm.

After seeing their investors operate in crisis mode this March, several digital health founders may feel compelled to re-evaluate their cap tables and possibly move forward with different investors for future raises. Startups were left with another conundrum after SVB’s collapse—which banking institution to choose next. SVB was known to offer startups loans during high-growth periods and took on companies that were too early to demonstrate product-market fit. While late-stage startups likely have the capital and credit requirements to bank with high-street institutions, nascent teams or those based outside of the US will need to turn to more restrictive and expensive alternatives to establish financial operations and secure loans.

The IPO Market and Q1

Q1 2023 logged another quarter with zero digital health IPOs. Digital health stocks started 2023 trading almost 50% lower than they did at the start of 2021, pushing some recently-exited players like Pear Therapeutics to explore going private. No later-stage digital health players felt compelled to venture into IPO territory this quarter, fearing that the market would yield bottom-barrel issue prices.

In December 2022, healthcare data startup Komodo Health raised $200M alongside a restructuring plan that laid off 9% of its workforce. In January, hybrid care provider Carbon Health closed a $100M Series D while also trimming its RPM and chronic care divisions and completing its second round of layoffs.1 That same month, nurse staffing solution Shiftkey announced its $300M raise, accompanied by a quartet of new executives. Connected fitness startup Tonal is rumored to be pursuing private funding at a $200M-$300M valuation, a nearly 90% decline from the $1.9B valuation it floated back in September 2022.

Regulatory Developments and Adapting Digital Health Startups

If circumstances weren’t treacherous enough, digital health startups are bracing for impending regulatory changes. In Q1 2023, an acronym soup of federal agencies (FDA, CMS, DEA, FTC) announced preliminary steps and timelines for refining policies across digital health. These revised guidelines have far-reaching impacts, affecting telehealth reimbursement, controlled substance distribution, healthcare service pricing and rebates, and patient data management. Top of mind is the announcement to end the COVID-19 public health emergency (PHE), which is slated to expire on May 11, 2023.

In the realm of telehealth delivery—perhaps the biggest area of healthcare expansion during the pandemic—telemedicine will officially lose its status as an excepted benefit2 and certain federal penalties for HIPAA non-compliance of telehealth platforms will be reinstated. In alignment with PHE’s conclusion, other government bodies are rolling back pandemic-era measures. State agencies are beginning to unwind expanded Medicaid coverage in conjunction with the expiration of a 2020 federal provision requiring continuous enrollment.

States resume disenrollments, anywhere from 5 to 14 million Americans stand to lose Medicaid coverage and associated benefits, with the hardest-hit populations being low-income youth and working individuals without employer-sponsored plan access. In terms of data privacy and security, Congress introduced the Upholding Protections for Health and Online Location Data (UPHOLD) Privacy Act to regulate companies’ use of health data, the FTC settled investigations into BetterHelp and GoodRx with hefty fines, and the FDA enhanced cybersecurity requirements in regulatory applications for medical devices. Finally, on the billing and coding front, CMS issued its 2024 Medicare Advantage Advance Notice to root out aggressive upcoding practices.

Despite holding the promise of delivering superior patient outcomes while lowering healthcare costs, many providers remain reluctant to embrace value-based care (VBC) reimbursement models. Progress toward VBC adoption hasn’t achieved its potential yet, hovering around 60% of all payment models from 2018 to 2021, with the remaining 40% comprised of traditional fee for service (FFS).

Though some providers simply are hesitant to abandon the FFS model that has served them well, others are leery of the technological and management challenges they associate with VBC models. According to consulting firm RTI Health Advance, these include:

• Administrative complexity within the value-based payment ecosystem
• Transitioning upside risk-only to fully accountable care; many providers are challenged to operationalize programs and afford the necessary time and finances
• Value-based models must incorporate and address specialty care as part of the continuum of covered services
• Health equity plans now are required as part of new value-based contracts with the Centers for Medicare and Medicaid Services (CMS) 

The CMS Innovation Center set a goal for all Original Medicare beneficiaries and most Medicaid beneficiaries to be in VBC relationships by 2030. These risk-based care models are designed to encourage proactive care, better population health and reduced spending across the healthcare spectrum. To meet that deadline, provider organizations will need technology tools for administering relationships within a value-based network. 

How Value-based Administration works

VBC networks are comprised of multiple stakeholders that may include hospitals, health systems, private practices, payers, accountable care organizations (ACOs), clinically integrated networks, social service networks and community-based organizations (CBOs). Successful implementation of value-based programs, therefore, requires complex hierarchy support for onboarding, data capture, data digitization, payments, and data exchange. These technologies must support social determinants of health (SDoH) and facilitate value-based payments, quality reporting and other use cases. 

Within VBC networks are many-to-many relationships in which an entity in one network may be engaged in several networks under various contractual engagements with other entities. Such a “network of networks” can work only with an infrastructure that supports the hierarchies between these entities. The architectural framework and processes used to run VBC networks collectively are referred to as value-based administration (VBA).

Figure 1 shows how VBA helps stakeholders across the healthcare continuum – providers, payers, patients, and CBOs – eliminate barriers to participating in a VBC network while also delivering measurable clinical and operational benefits.

Inadequate digital infrastructures

Most healthcare organizations, however, lack the digital infrastructure necessary for VBA. “We can’t graft a new digital, platform-based healthcare system onto healthcare infrastructure designed to support traditional operations and care models,” Mayo Clinic President and CEO Gianrico Farrugia writes in an article for the World Economic Forum. “Healthcare needs transformation. And to truly transform healthcare, we must simultaneously build physical and digital frameworks to meet the evolving needs of patients worldwide.”

Fortunately, healthcare organizations can implement VBA without embarking on a costly rip-and-replace strategy. This can be done through a platform infrastructure that can be deployed as a DaaS (Data-as-a-Service) or as PaaS (Platform-as-a-Service) or the traditional SaaS (Software-as-a-Service) model.  Such an infrastructure allows partner firms and/or clients to use existing applications served up via microservices or extend/create microservices and business applications for their own needs.  

What’s needed to enable VBA 

To fully leverage relationships in a VBC network, providers must: 

1. Implement a robust cloud-based data infrastructure to allow real-time clinical decision-making, information sharing and analytics
2. Realign downstream reimbursement to include both medical and non-medical providers (behavioral health services, drug treatment centers, etc.)
3. Incorporate SDoH resources and partners, such as CBOs
4. Have a dashboard view into real-time performance against all contracts 

An integral part of effective VBA infrastructure is ML (Machine Learning) and Artificial Intelligence (AI) technologies.  A key to implementing digital transformation is data digitization and amalgamation of that data with structured and external data sets so that a 360-degree view of the patient can be achieved to provide actionable insights to Payers, Providers and Patients.  AI technologies, coupled with ML algorithms in a robust data engineering framework that enables to-and-from integration between systems with this digitized data, are needed to make this a reality.  These facilitate better automation of tasks and decision-making processes since data-driven insights require digitized data in order to automate processes. A set of secure and scalable cloud-based microservices – on which different applications and integrations are built – then helps facilitate data interoperability as well as opportunities to build/partner/deploy different workflow-based applications for the end users. 

Final thoughts

Though structural and technological barriers impeding VBC adoption persist, many large healthcare organizations are working with technology partners to improve patient outcomes and reduce healthcare costs. Implementing VBA to manage VBC initiatives will empower healthcare organizations to deliver on the full promise of patient-centered, value-based healthcare.

About Rahul Sharma

Rahul Sharma is the CEO of HSBlox, which enables SDOH risk-stratification, care coordination and permissioned data sharing through its digital health platform.

About Lynn Carroll

Lynn Carroll is the chief operating officer of HSBlox, which assists healthcare stakeholders at the intersection of value-based care and precision health with a secure, information-rich approach to event-based, patient-centric digital healthcare processes – empowering whole health in traditional care settings, the home and in the community.  

What You Should Know:

• Uber Health, Uber’s healthcare arm, today announced same-day prescription delivery on its HIPAA-supported, centralized platform.
• For the first time, those using Uber Health—including healthcare providers and health plans—will be able to manage prescription delivery from any pharmacy in their service area through the same platform they already use to coordinate transportation for patients. This launch enables providers to offer a full suite of care solutions that extend beyond the four walls of a clinic and is designed to improve patient experiences and health outcomes.

Enabling Health Systems to Give Patients Seamless and Direct Access to Prescriptions

Today’s news furthers Uber Health’s mission to optimize how patients access care. The platform allows connectivity to the key services providers require to address patient needs including prescription delivery, stress-free rides, and soon, the delivery of healthy food and over-the-counter medicine for those who need it most—including Medicare Advantage and Medicaid beneficiaries.

When Uber Health launched in 2018, the business focused primarily on streamlining non-emergency medical transportation (NEMT) options, enabling patient populations—especially underserved and vulnerable communities—to get to and from medical appointments. While transportation is an important social determinant of health, it’s only one piece of the patient care puzzle. For example, a patient discharged from a hospital regularly requires a ride home and to follow-up appointments, as well as new prescriptions. Launching prescription delivery powered by ScriptDrop on the Uber Health platform ensures organizations can fulfill their duty of care obligations to patients by arranging direct, same-day delivery of their prescriptions while tracking when they arrive, enabling them to fully “close the loop.”

The tracking of care delivery across multiple disciplines promises a paradigm shift in an industry where providers and health plans could lose sight of patients outside of a provider’s office. Imagine a patient with a chronic kidney disease diagnosis who regularly needs transportation to specialist appointments that result in prescription changes of critical medications. Rather than burdening the patient with homework, Uber Health furthers the patient care team’s ability to arrange these services directly and track that they occurred. Uber Health facilitates critical touchpoints that enable payers and providers to provide maximum quality care at minimum cost.

“At Uber Health, we are building solutions that address lessons we’ve learned from years at healthcare companies operating in value-based care contracts. Too much time has been spent ensuring patients had a ride to their follow-up appointment, had picked up the right prescriptions, or had access to food,” said Caitlin Donovan, Global Head of Uber Health. “That’s why I’m proud to add a scalable prescription delivery solution to our platform that empowers care teams to fully close the loop. From prescription delivery and NEMT today to healthy food and grocery delivery in the coming months, Uber Health remains committed to delivering a more connected care journey through a single, seamless platform.”Powered by an integration with ScriptDrop, prescription deliveries can be facilitated through any pharmacy registered with the NCPDP within delivery coverage areas. Importantly, Uber Health allows for access to delivery coverage areas that include pharmacies dispensing medications covered by the 340B program, helping health plans and providers reach low-income and uninsured patients.