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Best practices for payers and providers to cooperate in the era of convergence


The Affordable Care Act has ushered in a new era of convergence among healthcare payers and providers.

For many, the Affordable Care Act marks the beginning of a new era of convergence in the healthcare industry. For both payers and providers, millions of newly insured lives and the shift toward value-based care have created new pressures. As the interests of payers and providers begin to align, there is a greater interest than ever before to keep healthcare quality high and costs down.

Data plays a key role in accomplishing this goal: with the advent of more care coordination programs, it’s become clear that claims data must be combined with clinical data in order to improve care coordination and drive new payment models. In order for payers and providers to jointly leverage claims and clinical data, their IT systems need to be aligned. Healthcare data is likely to grow exponentially over the next eight years, requiring new types of databases. Once IT systems are aligned and capable of handling various types and large quantities of data, effective population health management is possible.

Because payers can’t control (and often can’t access) the IT systems that providers and patients use (such as EHRs and patient portals) it’s hard for them to gather all the clinical data they need or collaborate with providers in an effective way. We have identified four emerging best practices and the technologies needed to enable them that can be leveraged by both payers and providers to enable effective and efficient population health management:

  • Aggregate, then analyze. Both payers and providers need semantic layer technologies that can normalize diagnosis codes and other clinical values that are currently expressed differently across multiple, disparate systems. A clinical data repository that serves as the fundamental “store” of normalized data is also needed. Once a broad set of claims and clinical data have been normalized and aggregated, analytics can be performed to create robust population health management workflows and care plans. The tools should automatically generate reports and dashboards that deliver data to the point of impact, whether that is to physicians in the exam room, or provider-based and payer-based care coordinators.  It is the combination of broad and deep real-time data and delivery within the provider’s or care coordinator’s workflow that enables the best possible outcomes – on a macro population level as well as on a micro individual level.

  • Engage and empower patients/members with tools that educate and allow them to view, download and transmit their own comprehensive health records, electronically. This will require portals that include a personal health record, grant mobile access, support secure messaging and can be accessed by both patients and their designated caregivers. Just as importantly, patient engagement tools should be deployed at a level that makes sense for the patient.  A patient with two chronic diseases is likely to see five or more physicians on a regular basis but it is difficult to engage meaningfully with that patient across up to five patient portals.  A community-wide “umbrella” patient portal and mobile app can give patients a comprehensive or holistic view of their health.

  • Streamline communications and transactions to ensure secure clinical information sharing, timely pre-authorizations and reduce duplicative or unnecessary procedures. This will involve secure information exchange and transport (e.g., Direct exchange and eHealth Exchange), as well as identity management and enterprise master patient/master provider indexes (EMPI).

  • Be prepared for “Big Data.” The volume of healthcare data worldwide is expected to grow 50 times between 2012 and 2020. With advances like the newly announced Apple HealthKit, we are only at the beginning of an inflection point. Once data is added from other patient devices, such as Fitbit®, and genomics and proteomics, traditional IT systems with their relational database models will have a hard time keeping up.  Platforms that use “Big Data” models similar to those used in other data rich industries will become necessary. 

As partnerships strengthen between health insurers, providers, and members, it is important that value-based payment initiatives align with strategic initiatives, demonstrate value, and manage care toward a state of wellness. It’s a challenging operation, but one that can be achieved with an IT foundation designed to benefit all. As we lay the foundation today for the converged marketplace of tomorrow, getting payer and provider data on the same page is one of the first and most crucial steps. 

Suzanne Cogan is vice president of sales and client relationships, Orion Health USA.

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