In today's healthcare market, several different forces are pushing payers to integrate all aspects of patient care. To be successful, payer organizations must be able to facilitate access to the same information set, including both clinical and claims data.

As payers work to remain profitable and efficient in the new era of healthcare, they are increasingly finding that they need to embrace and fully utilize clinical data. Population health, consumerism and increased competition are some of the primary drivers of supporting access to integrated clinical information, and leveraging those forces will help payers perform effective data integration. Specifically:

Population Health:

The traditional models of Utilisation Management (UM)/ Disease Management (DM)/ Care Management (CM) have evolved to focus on population health. Payers and providers are now increasingly sharing risk through ACOs, bundled payments and capitation models, which creates the potential for a richer, better understanding of the clinical “picture” and facilitates conversations across care teams. In order to achieve this improved communication model, payers must have integrated clinical and claims data in near-real time to support accurate analysis of patient data and enable universal access to comprehensive, accurate longitudinal patient records.

Increased Competition and Consumerism:

Mergers and acquisitions have played out extensively in the last decade, and now more than ever, are resulting in a highly-consolidated, increasingly competitive market. Bigger, tougher competitors are vying for younger and more cost-efficient members, but the millennial cadre in particular wants quick, digital access to their medical and financial documents. This means payer organisations are more focused on building attractive, innovative products that bring together many new kinds of data, including fitness trackers, genomics, biometrics, personal health records and member perks for staying healthy.

These population health and consumerism trends mean that payers must rely on comprehensive, thorough data sets to be successful. One of the biggest challenges of integrating this information is gathering the data from the multitude of different sources it resides in, and then putting it to best use for providers and patients. For payer organisations, getting their data house in order to support coordination of care is a major challenge, but it can certainly be achieved with a solid focus on the basics. We will boil those down to two “A's”:

  • Acquisition: Comprehensively collect as much clinical, patient-generated, and claims data as possible by identifying all possible sources (e.g. hospital, provider, and allied health professional EMRs, claims files, patient monitoring devices and wearables); prioritising the sources and potentially incentivising them to submit data; using a robust integration engine to cost-effectively and efficiently connect to the identified sources.
  • Access: Create an easy-to-use platform with accurate, up-to-date data to get a comprehensive, longitudinal medical record into the hands of members, thereby attracting and retaining more members.

One of the most complex and critical aspects of population health management is developing an IT infrastructure that enables payers and providers to access and share the clinical information they need. Sharing information across care teams is the key to streamlining and automating clinical and financial processes, as well as providing patients with easy-to-use, timely and accurate information.

Keep an eye out for the next post in our payer series where we will discuss provider and payer alignment.