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Payers: Population Health's Key Collaborators

The advent of population health presents challenges and opportunities to payers.

By Mark A. Caron, CHCIO, FACHE, CEO, Geneia

For payers, increasing health costs coupled with the shift to value-based and risk-based contracts with providers means more impetus for delivering on the full promise of population health. In short, population health means improving the health and lowering the cost of care for an entire population or community. This is often the result of a new and collaborative type of partnership among payer, provider, employer and, ultimately, consumer that is based on shared responsibility for outcomes and cost.

The opportunity for payers is to become a key collaborator in the health of their population. To do so, they need to identify and understand which members are the highest cost, highest utilizers of healthcare. Other key questions that payers need to answer include:

  • Is a member's utilization appropriate?
  • Is the location of service appropriate for the need and does the facility provide high quality, efficient and effective care?
  • Can payers develop programs and partnerships with members, providers and employers to influence education, behavior and, ultimately, the appropriate level of care and support to impact cost?

An important starting place is the creation of a near real-time, holistic view of each member, one that integrates clinical information such as diagnoses, prescriptions and lab results with medical and pharmacy claims. The 360-degree view is used to identify and stratify members into populations and cohorts such as:

  • The Healthy, with the goal of keeping them that way by connecting them to health education, primary care and preventive services
  • The At-Risk, with the goal of preventing or delaying progression to chronic disease
  • The Chronically Ill, with the goal of slowing or halting disease progression

This integration of information allows payers to provide their members with personalized healthcare based on their health status and engagement preferences, and to create watch lists, care teams, alerts and, ultimately, longitudinal care capabilities. Longitudinal care plans deliver a complete and comprehensive long-term view of the member, one that yields the specific interventions that, for example, will help keep a member in an at-risk category such as pre-diabetic rather than progressing to a type 2 diabetes diagnosis.

Predictive analytics fueled by socio-psychographic and patient-generated data are layered on top of the 360-degree view of the member. Today's analytics deliver many new insights that positively impact population health, including individualized next-best actions, increasingly accurate predictions about who will successfully engage in a health-risk assessment or an oncology case management program, and care mapping for those needing immediate, imminent or ongoing intervention and action. The holistic member view enhanced by predictive analytics drives the right type of interaction with members to help them better engage in their own care.

Just as payers need a true and comprehensive view of each member, they also require accurate, real-time information about the total cost of care. By knowing and understanding the key drivers of cost, quality and efficiency, payers are able to prioritize high-value providers and create networks that best serve their members.

Similarly, members need tools that give them quality and cost information to help them make informed decisions about where and when to access care. Effective consumer-transparency tools help members engage meaningfully in their health. It is encouraging to know that today's advanced analytics platforms are able to effectively meet the transparency needs of payers, members and providers.

In the years following the passage of the Affordable Care Act, payers have created many more value-based and risk contracts with hospitals, physicians and other providers. Some estimates suggest that upwards of 825 accountable care organizations (ACOs) have been launched with roughly 28 million Americans (including 8.3 million Medicare beneficiaries) being served by an ACO. Many more are expected as providers form alternative payment models to contend with the Medicare Access and CHIP Reauthorization Act (MACRA) and the impetus of the Centers for Medicare & Medicaid Services (CMS) to move aggressively towards value-based reimbursement. ACOs and other risk-based contracts mean that payers and providers are more closely aligned with shared goals of improving healthcare quality and cost. They also have increased expectations about data and insights that help care providers guide behavior and decisions that result in shared savings while keeping patients happier and healthy.

Effective data and analytics platforms illustrate in a very user-friendly format the providers who are delivering care at its most efficient, effective and successful level and meeting necessary quality measures. Payers that share insights into utilization, quality and care measures, and outcomes of provider panels with hospitals and physician partners simultaneously improve member care while preserving a healthy business model for providers.

Lastly, many payers struggle with legacy systems and vendors they have cobbled together in an attempt to meet the sophisticated reporting demanded by hospitals, physicians and, increasingly, employers. Fortunately, comprehensive analytics platforms with robust predictive modeling and reporting capabilities can now provide that holistic member view and illustrate the true cost of care to effectively support risk-sharing arrangements. These platforms can improve provider satisfaction while producing millions of dollars in savings by sunsetting legacy software and support contracts, and improving business processes.

Undoubtedly, the advent of population health presents challenges for payers. Yet, they are exceeded by the opportunity to more effectively and efficiently engage with hospitals, physicians, employers and consumers to improve care, quality and satisfaction. Delivering the right type of care at the right time to the right member for the best value achieves meaningful population health and personalized care.

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