How Payers Are Collaborating In Population Health

By Mark Caron, CEO, Geneia

It’s no surprise healthcare costs are significant — and growing. CMS announced in July that healthcare spending is projected to accelerate again, increasing an average of 5.8 percent a year until 2024. As a share of the economy, healthcare’s growth is anticipated to reach nearly 20 percent by 2024, from the current 17.4 percent. The so-called silver tsunami of 10,000 people turning 65 every day and enrolling in Medicare is one of the principal drivers of the projected expansion in healthcare spending as is the Affordable Care Act’s coverage expansions.

Delivery on population health becomes even more important for payers — with the shift to value-based and risk contracts with providers as well as the aforementioned increasing costs. In a nutshell, population health means improving the health and cost of an entire population or community, often as the result of a new and collaborative partnership that relies on the payer, the provider, the employer, and ultimately, the consumer to share and be responsible for a larger piece of outcomes and cost.

Payers have a wonderful opportunity to become the crucial collaborator in the health of their population. In order to do this, they need to understand which members are the highest cost, highest utilizers of healthcare. Other key questions that payers need to answer:

• Is this member’s utilization appropriate?
• Is it occurring at the right type of facility that will assure quality, effectiveness, and efficiency?
• Can programs and partnerships with members, providers, and employers be developed to influence education, behavior, and ultimately the appropriate level of care and support to impact cost?

An important starting place to reach these goals is the creation of a near real-time, holistic view of each member. This should be one that integrates clinical information including prescriptions, diagnoses, lab results, etc. with medical and pharmacy claims. The 360-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

Integration of analytics allows payers to offer their members personalized health based on their engagement preferences and health status. In addition, they can create watch lists, alerts, care teams, 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 will, for example, 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-view of the member. Advanced 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 to satisfactorily engage in their own care.

While payers need a true and comprehensive view of each member, it’s vitally important to also have accurate and near-time information about the total cost of care. By knowing and understanding the key drivers of quality, cost, and efficiency in care, payers are able to prioritize high value providers and create networks that best serve their members. Similarly, members need transparency tools that give them quality and cost information to make informed decisions about where and when to access care. Effective consumer transparency tools help members meaningful engage 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 since the passage of the Affordable Care Act, payers have created many more value-based and risk contracts with physicians, hospitals, and other providers. Some estimates suggest that over 650 accountable care organizations (ACOs) have been launched with 70 percent of Americans living in an area served by one or more ACOs. 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 appropriating care, meeting necessary quality measures, and collaborating to deliver care at its most efficient, effective and successful level. 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 demands of hospitals and physicians — as well as the growing cohort of employers. Instead, there are now comprehensive analytics platforms that meet the previously identified needs of a holistic member view, robust predictive capabilities, and true cost of care while also enabling effective reporting and analytics capabilities that support risk-sharing arrangements. Typically, these analytics platforms improve provider satisfaction while producing millions of dollars in savings by sun-setting legacy software and support contracts and improving business processes.

Without a doubt, the advent of population health presents challenges for payers yet they are exceeded by the opportunity to become the crucial collaborator in the health of their population and the convener of hospitals, physicians, employers, and consumers to improve care, quality, and satisfaction. The right type of care at the right time to the right member achieves meaningful population health and personalized care.