Because of the wealth of information found in claims data—bills for service, lab work, medications, prescriptions, and more—today’s payer has a unique longitudinal view of the patient’s complete medical history.
This puts the payer in a unique position for understanding the finer points of the patient’s health narrative, including details like individual habits and potential gaps in care that could negatively impact their outcomes.
In fact, the information a payer has is often superior to what can be found in an electronic health record (EHR), especially as medical billing begins to require more and more details in order to facilitate effective reimbursement. For example, sometimes a patient’s personal information is sent to a payer without ever being put into an EHR, which makes the payer the only party that can (1) identify a patient that poses a financial risk before care is delivered and (2) take advantage of vital care opportunities before a patient has received services (e.g., providing adherence strategies to patients with histories of neglecting their medications).
However, if the payer learns to properly leverage their unique position and facilitate an exchange of information with the provider that could leave both parties acting proactively instead of reactively, gaps in care that result in poor health outcomes might be addressed.
The payer’s longitudinal view of patient data allows the payer to be a catalyst for improving the health of the community. Some payers, in fact, have even begun taking particularly aggressive stances by adding multi-payer solutions that offer value to (1) providers and clinicians, who can use the solutions to support value-based contracts across all their patients, and (2) patients themselves, who can take advantage of flexible payment options, which benefits payers, providers, clinicians, and patients alike. By turning their data into platform services that can be leveraged by the entire community, these payers take the basic provisioning of data a step further by analyzing it and delivering panels of information to providers in much the same way an in-house care management platform might.
While this requires an upfront investment by the payer, the provider who may not have the budget or ability to deploy data analytics solutions for its practice stands to benefit greatly from such an exchange.
Further, by subsidizing the cost of data analytics, the payer benefits from the financial rewards that come from helping the provider deliver the positive health outcomes that value-based arrangements demand. For example, I’ve observed a payer who sees its investments in its open-data platform, people, and processes as an opportunity to improve patient outcomes and ROI by collaborating more deeply with key providers, sharing some of their provider partners’ risks, and giving those provider partners an unprecedented advantage in the value-based payment programs they’re already participating in.
Despite all of this promise, payer/provider cooperation is still happening at a relatively slow pace, hindered by hurdles left over from a healthcare financial system that has long compartmentalized patient information. For the sake of their mutual success, payers and providers need to improve the sharing of information and align their interests in such a way that they can improve both financial results and care outcomes without incurring new losses. It will take the payer to make investments in its data and, in the end, everyone will benefit from better outcomes. This will make the payer’s sharing of its wealth of information more than just a great idea—it’ll make it a great business opportunity, too.
The original article can be found at the Gibson Consultants site here.