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Health plans look to collaborations to gain data, interoperability and efficiencies

'One truth will be available to all and ultimately to the payer as well,' says healthcare expert.

Susan Morse, Senior Editor

For insurers, the word right now is collaboration.

Specifically it's partnering with, and even acquiring, providers to integrate the data necessary to reduce the cost of healthcare.

The challenge of interoperability was thrown down by Centers for Medicare and Medicaid Administrator Seema Verma at HIMSS18.

"With some of the alliances that are forming, payers have to think about what the next business model is," said Trish Birch, senior vice president and Global Healthcare and Life Sciences Consulting practice leader for Cognizant Technology Solutions. "We see with the rise of the on-demand economy ... the value proposition for health plans will go away. It will evolve into an integrated delivery system like United acquiring providers." 

Recent examples include UnitedHealth Group's Optum buying DaVita Medical Group, OptumCare's plan to buy Reliant Medical Group and BayCare Health System partnering with Lumeris on a Medicare Advantage plan in Florida.  

At HIMSS18, an executive with Highmark Health said the health system couldn't have driven its health solutions and cost reductions without having an integrated model.

Highmark Health is an integrated care delivery system that has partnered with the Blue Cross Blue Shield Association to further its product and business model, said Sarah Ahmad, senior vice president of Complex Care and Innovation at Highmark. 

Ahmad and Jody Voss, vice president at BCBSA, talked about a new model called Vital, a process that shows whether a health solution will return the cost, care and experience impact that is hypothesized.

"We have access to all the data necessary to generate the evidence," Ahmad said. This includes, she said, "(the) medical cost savings, care outcome, and patient, provider or other user's experience with the solution."

Soon the Vital test and learn engine is expected to move from an internal platform to being accessible to health innovators and other payers, she said.

Provider patient records on diagnoses, procedures, labs, drugs, will flow between different healthcare touchpoints, including payers, according to Anton Berisha, MD, senior director of Clinical Analytics and Innovation, Healthcare LexisNexis Risk Solutions.

"One truth will be available to all and ultimately to the payer as well,"  Berisha said.

The sharing of information will automatically reduce or eliminate unnecessary and duplicative diagnostic workups, improve medication reconciliation, synchronized the use of drugs, reduce chances for adverse drug reactions, reduce or eliminate fraud and waste and decrease abuse trends with particular drug classes such as opioids, he said.

The availability of all clinical history will improve quality measurements such as HEDIS and star ratings and for risk adjustment efforts. 

"This directly translates into extra revenue, better reputation and increased patient satisfaction because of less financial burden and better clinical outcomes," Berisha said. "Proper interoperability implementation will result in vastly improved financial and clinical outcomes for both health plans and patients."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com