In uncertain times, it's critical to invest in your member relationships

It’s impossible to predict financial futures when so much remains unknown amid the coronavirus crisis. While the costs for covering coronavirus treatments have yet to be determined, hospitals and outpatient offices are canceling elective procedures and individuals are delaying or forgoing other care. As a new report from the Kaiser Family Foundation shows, the potential excess funds due to COVID-19 coupled with elevated premiums over the last 2 years have set the stage for unprecedented levels of potential MLR-based refunds across the health plan marketspace. Health plans with large individual, exchange, and fully insured lines of business will be especially hard hit.

This climate leaves health plan leaders facing several potential outcomes and choices. There may be a requirement to return premium dollars to members in accordance with MLR limits. There’s the potential for direct payments to providers or funding of reserves in order to prepare for increased utilization in the fall of this year into the next. 

As a result, health plan leaders are considering ways to manage investments and quality improvement initiatives that will be critical to navigating today’s crisis: the ability to deliver more value by re-imagining the relationship between health plans and people. By funding “quality improvement” initiatives that can help care teams monitor and support more members, organizations can not only manage MLR, but can future-proof their organization for a post-COVID-19 world. 

How to ensure you meet quality improvement criteria

Many leaders are evaluating the long-term benefits of adding digital health technologies that will help them better manage member populations and keep vulnerable populations both connected and safe. But how can you tell if your initiative or expenditure will count towards the medical spend for MLR? 

As defined by NAIC, qualifying expenditures are “activities that improve healthcare outcomes, reduce medical errors and improve patient safety, encourage wellness and prevention, and reduce rehospitalizations.” HHS also mandates that the expenditure “must be capable of being objectively measured and of producing verifiable results and achievements.”

Initiatives that are critical during today’s crisis—and beyond


1. Amplifying your ability to conduct effective case management, care coordination, chronic disease management, and medication and care compliance to improve outcomes.

As the pandemic continues, it will be all the more critical for organizations to have the ability to extend therapeutic relationships at scale to those who are most vulnerable to the virus.


2. Comprehensive care transitions programs that can prevent hospital readmissions.

In a world of cancelled or virtual doctor’s appointments, more and more patients are turning to their health plan for comprehensive resources, counseling, post-discharge planning, and follow up from healthcare professionals.will be all the more critical for organizations to have the ability to extend therapeutic relationships at scale to those who are most vulnerable to the virus.


3. Evidence-based, peer-reviewed mobile health education programs that can improve patient safety and reduce medical errors.

Health plans need a channel during this crisis to support and educate concerned members with the latest digestible guidance.


4. On-demand support to promote wellness and health.

As people may forgo preventive screenings and appointments during this crisis, it will be more important than ever to offer virtual access to healthcare professionals who can help people better manage their health under especially difficult circumstances.


5. Rigorous measurement capabilities that can produce verifiable results and achievements, as well as drive continuous improvement.

Not only will robust analytics give you the opportunity to demonstrate quantifiable business value, but you’ll also gain the ability to understand the needs of the most vulnerable in real time, at scale, so care teams can respond most effectively.

Key takeaways

In a dynamic, ever-changing environment, we know at least one thing for certain: The pandemic has highlighted the need for innovation across the healthcare landscape. An investment in your digital health capabilities can not only help you reduce MLR-based refunds, but will position your organization to better weather this storm and deliver increased value to members and customers in the months to come.

This article is written for educational and general information purposes only and does not constitute specific legal or regulatory advice. This article should not be used as a substitute for competent legal or regulatory advice from a licensed professional in your state.

Want to learn more? Take our interactive MLR master class for health plan executives. May 20 at 1PM ET