As the healthcare industry continues to transition to value-based models, more health systems are becoming insurers. Intermountain Healthcare’s health plan divisions, SelectHealth, has been around for 30 years. Intermountain has a long history of striving to improve patient care and reduce unnecessary expenses. Now Intermountain is passing its cost savings onto customers through its new health plan, SelectHealth Share, which locks in yearly rate increases at approximately four percent. There are numerous financial risks associated with this plan, but Intermountain has the systems and infrastructure in place to manage these risks. The new plan requires close collaboration from all stakeholders: unaffiliated providers must adhere to Intermountain’s changes, like using an EMR; employers must pay at least 70 percent of average premiums; and employees need to proactively manage their health using online tools. Intermountain’s attempts to make coverage a “predictable expense” deserve recognition.
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OSF HealthCare has committed that 75 percent of its primary care patient will be part of a value-based program by 2020. The organization’s leaders knew that success depended on how well they managed their data and decided to build a data warehouse in-house. They recognized that beneficiary claims data was essential to understanding their population better. To get that claims data, however, was no easy task. This required patient matching through master data management and getting buy-in from leaders and physicians throughout the health system. Then, they prioritize where to start efforts using the 80/20 rule and using that as a guide, loaded the claims data.
As the healthcare industry moves closer to value-based care, there are a lot of projections about the changes that will occur in the near future. This article discusses seven of the top trends the industry is focused on: (1) physicians start to feel the financial impact of CMS’s rules; (2) the use of technology in healthcare is exploding; (3) financial viability is a key concern for CEOs; (4) reducing exposure to risk performance is becoming more important; (5) interest in population health management continues to grow; (6) outcomes improvements will continue to increase; and (7) collaboration between providers and payers will increase.
Transparency in healthcare will drive cost and quality improvements for payers, providers, and patients alike. Consumers want to know true out-of-pocket costs and quality information for their providers. Physicians want to know about their potential referrals partners’ level of quality. In addition, transparency between payers and providers needs to improve to drive down costs. This trend presents challenges such as limited/siloed data access and cultural change. An EDW and analytics system can help transform a health system, improving value and patient/staff satisfaction.
Healthcare payers and providers are using new types of financial arrangements to motivate process improvement. i. Pay for Performance-a straightforward inventive that rewards improvement based on established metrics. ii. Bundled Payments-a payer gives a single payment for all provider services, holding providers accountable for reducing waste and eliminating duplication iii. Accountable care organization-a total-cost-of-care system that rewards or penalizes based on the total cost of a patient population All three arrangement mean that payers and providers must work together to figure out how to improve processes. A three-system approach is the best way to drive improvement and healthcare transformation. i. Analytics System-the technology and expertise to gather data, make sense of it, and standardize measurements ii. Best Practice System-standardizing best practices iii. Adoption System-standardizing organizational work and team structures
Payers and providers agree that focusing on quality is important. CMS, the HEDIS, and the Joint Commission all have quality measures hospitals need to consider. Payers have their own set of quality initiatives. Healthcare data is an important part of determining the performance of those quality measures. But complications abound when trying to combine payer and provider healthcare data and measurements. The result is a time-consuming process resulting in reduced ability to analyze the data to drive improvements. Having payer and provider data available would be a huge advantage and is possible through a healthcare enterprise data warehouse. A Late-Binding™ approach provides the flexibility and adaptability needed for quality initiative teams to effect real change within their organization.
Accountable care is changing the way Payers and Providers look at their healthcare data. Many healthcare enterprises believed that their Electronic Health Record (EHR) would be the silver bullet to this data problem, but they are beginning to discover the limitations of the EHR for managing at the enterprise-level all of the information necessary for effective risk-sharing. Health information exchanges (HIEs) help eliminate data silos but are not designed to store or analyze the data with the level of sophistication required for supporting a risk-sharing model. The reality is, until now, providers and payers have lacked consistent incentives to share data.
Payers and providers have the same goals—both want to improve patient care and lower the cost trend. Obviously, collaboration is key. Bobbi identifies 3 collaborative best practices to pave the road for a productive, beneficial relationship: 1) clinical measurements and metrics, 2) payer-provider transparency, and 3) joint clinical improvement.