The following is a guest article by Deborah Dean, Technology Advisor, BioIQ.
As healthcare makes the transition to value-based care, use of data analytics has become an essential tool for both payers and providers. This article explores progress so far and opportunities for payer and provider partnership on data-driven care initiatives. How can payers and providers work together to turn data into consumable information that drives positive clinical and financial outcomes?
Over the years, payers have created sophisticated data analytics groups for the purpose of contract pricing and actuarial work to meet different payment models. Some health plans, especially the larger ones, rely on a shared risk model using data analytics to calculate risk in pricing their business. This involves the use of numerous algorithms for claims adjudication models that inform plan design. They look at potential fraud and have done a good job with loss prevention.
Health systems are making progress with data models but have yet to reach the analytics maturity of payers. Since the 1990s, health systems have used data analytics in the clinical area to expand services and determine where to build facilities. Today the focus is more on advanced analytics for patient care to further a consumer-centric approach based on data-driven engagement strategies.
The next step for providers is to use analytics and artificial intelligence to interact with their patient base and tailor each person’s healthcare journey with the right communications strategy. That means continually listening, learning and changing to personalize the patient experience and deliver the right message at the right time to drive action. Payers use a similar approach with claims by constantly evaluating and refining their plan design.
Providers have a vast amount of infrastructure for their clinical systems including labs, revenue cycle and ADT. However, integrating data from different systems requires establishing a repository—a living, breathing database that brings all the data together with artificial intelligence on top. Once you break down the silos, business dashboards enable management to make real-time collaborative decisions for their communities.
Using advanced health analytics personalizes the patient experience. Every patient that goes into a health system has individual preferences on the ways that they want to be engaged and treated. Determining how to engage individuals on their terms breeds better outcomes in their clinical care. Ultimately, a health system’s goal is to provide the best services for optimal treatment and prompt discharge. How do you determine the best treatment modality and promote engagement throughout the patient’s clinical and financial journey? Knowing the patient’s social determinants of health (SDOH) is a critical factor.
The focus on SDOH can serve as a bridge for payers and providers to collaborate. Historically, they have been adversaries and have not worked together on behalf of patients. Sharing information such as SDOH risk factors about the patients they both serve holds the potential to promote preventive care and reduce healthcare costs. Payers and providers are increasingly looking at SDOH to provide treatment in the most cost-effective manner. Successful initiatives will depend upon partnership and advanced technical capabilities governed by transparency, accountability and integrity.
One option to facilitate alignment is to set up an independent third-party, nonprofit organization to encourage open dialogue about patient care. Payers and providers can both then provide information for the betterment of care coordination and outcomes. Granted, sharing large amounts of data is a massive initiative requiring strict adherence to privacy and security protocols. Thus, the best approach is to start small with certain people designated to share information across the payer/health system spectrum, and then move to broader sharing of information.
Consider the benefits of bringing both sets of data together from an analytics standpoint. The shift to a collaborative model could revolutionize the way we deliver care and reduce costs in the era of value-based payment. In fact, we’re now hearing the term “payvider” to describe payer-provider partnerships created to reduce financial risk, increase profitability and improve patient care. These joint initiatives are expected to increase in 2020 and beyond.
Patients will drive the sharing of information as they push for engagement through portals and other forms of communication. They want better treatment, convenience and an active voice in decisions about their healthcare. Patients who feel engaged and empowered to take action will demand collaboration as part of their care. The more payers and providers share information, the better the patient experience will be. Together we can transform value-based care delivery for payers, providers and consumers.
About Deborah Dean
Deborah Dean is Chief Analytics and Technology Officer at BioIQ. With more than 25 years of industry experience, Dean is a highly respected technology executive with extensive C-level expertise. Her experience includes operations, technology, data integration, analytics, applications development, informatics and technical infrastructure. Most recently, Dean served as executive vice president of MiMedx where she had broad responsibilities including technology, informatics, clinical trial management, and quality and regulatory oversight. Prior to joining MiMedx, she was president and chief operating officer of HolaDoctor, a leading Hispanic digital site. Additional experience includes Matria Healthcare, where she served as executive vice president and chief technology officer and was awarded CIO of the year by the Georgia CIO Leadership Association (GCLA). She has also served as senior vice president of research for Quovadx, Inc. (now Lawson software) and, earlier in her career, held a range of positions in data warehousing and informatics for Medstat. Dean earned a bachelor’s degree in health services administration from Arkansas State University. She lives in Atlanta and is on the board of directors of Glytec and Special Olympics Georgia.