What Do Health Plans Need To Transform UM, CM, and Pop Health?

53 health plan leaders weigh in

Current legacy tools are hindering the effectiveness of utilization management (UM), care management (CM), and population health management (PHM), leading to a fragmented and frustrating experience. Help your organization drive down costs and improve outcomes with exclusive access to comprehensive insights from top health plan executives about the current state of UM, CM, and PHM as of 2024. Discover key strategies to break down the barriers impeding progress.

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Is your health plan meeting its care management (CM), utilization management (UM), and population health management (PHM) goals? If not, you’re not alone.

A new independent survey of 53 health plan leaders finds that many are struggling with ineffective tools that prevent them from fully integrating the growing influx of member data—medical, social, behavioral, genetic—into their workflows. As a result, legacy tools are hindering health plans from strategically leveraging data to reduce costs, improve outcomes, and streamline efficiencies.

Our latest report, based on the survey findings, further explores what is really required to drive impactful changes to UM, CM, and PHM programs.


53 Leaders Surveyed

Regional payer 0

Gov't program plan (Medicare Advantage, Managed Medicaid, or both) 0

National payer 0

Managed services organization 0

Provider sponsored health plan PPS/ Payvider 0

TPA- Medicare or Medicaid 0

Tech-enabled and/or venture-backed health plan 0

Preview: The State of Utilization Management

One troubling finding: Just one-third of health plan execs say their UM tools are “very effective” at providing all of the data necessary for timely review and approval.

Clearly legacy UM tools are not as effective as health plans need them to be – and there is room for improvement when it comes to identifying health events in time to impact utilization of services and minimize provider abrasion.


Leaders’ Frustrations with Legacy UM Tools:

Inefficient workflows 0

High costs associated with data problems 0

Provider abrasion 0

Staff complaints 0

Member complaints 0

Lack of coverage across member base 0

Why? Fragmentation and Lack of Integration

Data is fragmented 0

Data doesn't currently flow into workflows 0

Data integration is burdensome 0

Data is siloed 0

Software is cumbersome 0

Ease of use of the tool 0

Lack of data transformation 0

Data is inaccessible 0

Legacy UM tools are just not easy to use, and, in general, the UM process lacks efficient automation.

Given the critical role Utilization Management processes fill for health plans, these legacy solutions must be improved with strategic data use, AI, and automation to sustain member engagement, reduce costs, and improve health outcomes.


Preview: The State of Care Management

The Biggest Barriers to Member Engagement

Lack of member engagement tools 0

Lack of personalization for members 0

Lack of ability to react in real time 0

Too much lag time between health event and ability to intervene 0

Lack of member self-service tools 0

Lack of visibility to member health journeys 0

The research suggests that implementing updated technology that provides quicker access to data and insights would significantly enhance CM. Today’s care management technologies, strategies, and workflows are inadequate for members’ quickly evolving and increasingly complex needs.


Care managers need resources and insights that enable them to engage members at the health inflection point rather than 90 days after the fact. And they need the ability to create workflows based on member preferences, digital member assessments, and more.


Execs Agree. A Holistic View of Members on their Care Journey is Very Important

Moderately important 0

Very important 0

During our webinar, from January 18, 2024, four expert speakers shared insights from our recent survey of health plan leaders.


What’s holding health plans’ Utilization Management (UM) programs back from improving efficiencies, reducing costs, and driving better outcomes? Legacy tools.


Our upcoming webinar with Becker’s Payer Issues will examine the current state of care management, including the top barriers and how organizations can break through them


Utilization Management

January Blog Image

What’s holding health plans’ Utilization Management (UM) programs back from improving efficiencies, reducing costs, and driving better outcomes? Legacy tools.

Read More


The state of Utilization Management? Fractured and Frustrating, but the Future is Clear. Our experts examined exclusive research and discussed the future of UM


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