Successful population health management is not possible without data. The form that information takes depends on the role being played by a particular player in population health management: provider, patient, or payer.
With passage of the Affordable Care Act and the movement toward value-based reimbursement, health plans find themselves facing challenges similar to those of the providers they’re working with in the pursuit of accountable care and population health.
“The landscape is certainly changing and there are many changes. How payers are interacting with providers really depends on the type of structure they have set up,” says the newly-appointed IDC Health Insights Research Director Deanne Primozic Kasim.
“In the last two to three years in particular, there have been many developments in terms of providers forming patient centered medical homes and accountable care organizations, not just with Medicare but also with some payers doing their own types of ACO arrangements,” she continues. “That has a different dynamic for the types of data being given to payers and the kinds of reimbursement coming back to providers.”
The challenge is made harder by the series of healthcare mergers, acquisitions, and partnerships that have an impact on reimbursement for providers and payers. ” You see these hospital systems just eating up provider practices and as their operations are being integrated there are more billing processes are in place in terms of how these groups now get reimbursed,” adds Primozic Kasim.
In looking for guidance in the area of accountable care in particular, Primozic Kasim admits that health plans can look to the approach taken by the Centers for Medicare & Medicaid Services (CMS) in its Medicare Shared Savings Program (MSSP) and Pioneer ACO Model, but that does not necessarily provide real clarification.
“What Medicare has put out there is being used as a guideline, but there is unfortunately not one roadmap,” explains Primozic Kasim. “It is a real challenge for payers in looking at the types of quality metrics they are going to use as different programs pop up, including what they do with the federal government if they choose to play there. There are so many quality metrics that they are challenged to keep up with them.”
One thing that is clear to payers is the need to understand individuals as consumers as well as patients where Primozic Kasim sees great potential for improvement.
“There isn’t one-size-fits-all just like there’s not one type of consumer or patient,” she stresses. “It’s really about trying to reach people by respecting their different healthcare literacy overall, their social use of technology, their access to technology, and what’s going to hit home with them because there are different messages and cultural and demographic concerns as to how to reach people.”
According to the research director, certain payers have a leg up on others in the makeup of their patient populations. “The ones that have more of a target population, such as the Medicaid and Medicare Advantage plans, have an advantage over the larger national plans because their patient population is a lot more focused and more centered geographically as opposed to those plans that are trying to cover everybody in different market segments,” claims Primozic Kasim.
Getting to know their patient populations is leading payers toward gathering intelligence through business and clinical analytics solutions and services. Given the inchoate of healthcare analytics choosing the right vendor partner or partners is not an easy one.
“In terms of analytics, there is not one vendor that has a complete, defining market share,” says Primozic Karim. “There are many companies out there doing everything from the backend edge server to some of the more clinical analytics and looking at population health of these exchange populations because clearly setting premiums for this is going to be key to moving forward.”
For value to replace volume in healthcare, premiums and reimbursements must be properly configured. Without meaningful insight into the needs of the provider and patient populations, payers will not be able to rise to the requirements of this new era in healthcare.
Source: www.ehrintelligence.com; Kyle Murphy; April 30, 2014.