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.