Healthcare payers today must develop new business models to address the industry’s mounting challenges around cost, access, and quality. The best emerging models are simple and aligned, accommodate all stakeholders’ needs, and center on the patients/members.
Five key payer opportunities provide a framework for new models that will support the healthcare transformation goals of lower cost, better quality, and increased access:
Understand the impact of the Affordable Care Act.
Be ready for potential shifts due to regulatory impacts.
Understand how social determinants of health impact members.
Focus on provider relations.
Prepare for future trends.
To stay in sync with healthcare’s transition to value-based care, payers today must develop the analytics capability to support alternative payment models and drive more value to their members. Payers can follow an analytics roadmap to develop a strategy that extends their data, analytics, and risk management expertise to meet growing demands.
The analytics roadmap helps the payer meet these common challenges of establishing a data-driven culture:
Recruiting and retaining high-quality providers in a competitive market.
Managing increasing numbers of high-risk/high-cost members with limited resources.
Efficiently reacting to federal and state legislative and payment changes.
Controlling the rising costs of healthcare services and pharmaceuticals.
Employers are always looking for ways to reduce one of their biggest expenditures–the cost of providing health insurance to employees. Many employers have explored solutions such as adding wellness plans, reducing usage, and providing different provider access mechanisms, all with modest success.
Stemming the rising costs of health insurance requires management to understand and improve healthcare outcomes for their employee and dependent populations. Changing the future of employer health insurance will require a multi-faceted approach:
Driving additional value by reducing utilization of healthcare services within these employer populations.
Utilizing a wider lens through which to view performance of various providers, then making decisions based on those who are consistently providing low cost, high quality care.
Employer will need to combine their data with other companies across a geographic region to get a better picture of the provider landscape than has ever been possible before.
Customer journey analytics uses machine learning and big data to track and analyze when and through what channels customers interact with an organization, with an aim to influence behavior (e.g., buying behaviors among retail customers). Similarly, healthcare organizations want to influence health-related behaviors, such a taking medication as prescribed and not smoking, to improve outcomes and lower the cost of care. In a partnership with an analytics services provider, a payer organization is leveraging customer journey analytics among healthcare consumers to identify the best opportunities and channels for patient outreach. With this analytics-driven engagement strategy, the payer has found an opportunity to significantly improve patient engagement—a predicted overall increase from 18 percent to 31 percent.
As healthcare transitions from fee-for-service to value-based payment, payer organizations are increasingly looking to population health management strategies to help them lower costs. To manage individuals within their populations, payers must become data driven and establish the technical infrastructure to support expanding access to and reliance on data from across the continuum of care.
To fully leverage the breadth and depth of data that an effective health management strategy requires, payers must address six key challenges of becoming data driven: