Dealing with this challenge
“With multiple stakeholders trying to manage a patient’s care, there is immense opportunity for enhanced stakeholder interoperability to reduce disparate systems of care and align a network on one centralized platform,” Gagalis says. To share existing data, synchronize workflows and streamline processes between various stakeholders, payers, and providers should use care coordination technology that collects, analyzes, and shares information across the continuum.
Because payments in these models are contingent, at least in part, on the provider meeting certain metrics, it is imperative that those metrics are within the provider’s control, Cook Rush says. Also, it’s important from both parties’ perspectives that the metrics and data being measured are an actual assessment of improved health that will result in cost savings. “When entering into an outcome- or value-based contract, healthcare executives need to analyze historical data to ensure that the metrics are an attainable and appropriate measurement of health improvement,” she says.
Furthermore, as parties enter into these types of agreements and providers take on additional responsibilities and financial risk, it is important to assess whether the relationship will be subject to regulation under state insurance or managed care regulations, Cook Rush says. Because of the shift in responsibilities, the provider may be required to register or seek licensure as a regulated entity. For instance, the California Department of Managed Health Care has oversight of risk-bearing organizations, which can encompass physician-owned entities that bear risk. A review of state laws and regulations should be conducted when structuring the relationship.
Challenge 3: Using big data
To gain meaningful data insights, payers must adopt technology that makes the data actionable and contextual—using it to inform clinical decision-making and improve care management, Gagalis says. Health plans should seek solutions that not only provide data from disparate sources, but that can also display data in a way that is meaningful and actionable.
For example, the recently enacted California Consumer Privacy Act requires businesses to inform consumers about the personal information they collect and how it will be used; consumers’ personal information cannot be used for any purpose that wasn’t disclosed at collection, Cook Rush says.
Dealing with this challenge
Businesses need to be cognizant of state and federal privacy laws that may limit how big data can be used. Monitoring data’s security is also key. The information may constitute protected health information under Health Insurance Portability and Accountability Act or personal information under state privacy and security laws. “Companies may need to employ protections such as firewalls, encryption, and other security measures to guard against unauthorized access to the data,” Cook Rush says. And, if data is hacked or stolen, there is the potential that individuals may require notice of the incident.
Challenge 4: Implementing cybersecurity measures
Healthcare entities are continuing to see a rise in the number of cyberattacks. Attackers are getting smarter and more persistent. Employees are getting more comfortable working with electronic information (which sometimes makes them more relaxed and susceptible to oversights). Records maintained within the healthcare industry are valuable due to the vast amount of information contained therein, and providers typically maintain several electronic systems containing patient information (e.g., electronic medical records, billing, practice management, email), all of which are susceptible to attack, Fleming says.