Artificial Intelligence. Predictive Analytics. Bigdata. Machine Learning. HealthCare Executive Group. Benefits Costs. Patient Outcomes. Quality Standards. STAR ratings. Profit Margins. Improving Efficiencies. EQ Health Solutions. Solving the Rubik’s Cube of Payer Data. Health Plans. Payer market. evaluating healthcare analytics vendor. Data Security. Tools and Technologies.

Insight on Solving the Rubik’s Cube of Payer Data

By | Data & Analytics, HCEG Top 10, Payers, Sponsor, Webinar Series | No Comments

Healthcare payers are sitting on a lot of data, from eligibility data, to claims data, to data obtained from 3rd parties, to data derived from analytics. It’s no surprise that over the last decade “Data & Analytics” has been a consistent entry on the HealthCare Executive Group’s Top 10 list of challenges, issues, and opportunities facing healthcare executives. And currently ranked #1 on the 2019 HCEG Top 10 list. To help share insight, ideas, and actionable information supporting data and analytics, our sponsor partner EQ Health Solutions presented our June Webinar Series event: Solving the Rubik’s Cube of Payer Data.

Chief Strategy & Growth Officer Mayur Yermaneni and Marina Brown, RN BSN, Vice President of Clinical Programs, from eQHealth Solutions shared information and insight on the following four topics:

  • The current state of the payer market and future considerations
  • The Rubik’s Cube of Payer Data – the Present Debacle
  • What tools and technologies will lead to continued payer success?
  • Top six things to consider when evaluating your healthcare analytics vendor

Highlights from Solving the Rubik’s Cube of Payer Data

This blog post presents some highlights from the webinar and provides access to additional information from the webinar. You can also check out this Twitter Moment summarizing live Tweets from the webinar.  The complete recording of the webinar can be found here. To jump to the specific place in the recording, click on the timestamp range [HH:MM] that accompanies each transcripted section below.

HealthCare Executive Group Top 10 list. EQ Health Solutions. Solving the Rubik’s Cube of Payer Data. Health Plans. Payer market. evaluating healthcare analytics vendor. Data Security. Tools and Technologies.

For more information on how EQ Health Solutions can advance your organization’s data and analytics initiatives and programs, contact EQ Health Solutions.

Current State of the Payer Market and Future Considerations

Mayur Yermaneni shared some insight into current data and analytics capabilities of healthcare payers: [7:16]

Some payers are firmly in an average spectrum of recognizing current trends and some and some payers are still in the infancy stages of recognizing the impact of these trends. So, I’m trying to generalize some of these themes so that everybody can actually benefit from it.

Margins are Decreasing

So, across the board, one of the key things, and I guess this is not unique to the payer market itself, is that margins are decreasing. With new regulations coming on board there are more and more cost burden associated with the payer market. Some payers are becoming a financial institution from that standpoint [of increasing regulatory burden.]

Mega Mergers

You see this a lot more in the bigger payer, payers like Aetna’s acquisitions, United’s acquisitions, WellCare and all these acquisitions that are happening is [intended] to counter their decrease in margins by creating economies of scale that they could benefit by actually saying: “If I can actually acquire another of these entities, then I can create a cross burden rate across these common units and hopefully benefit from the margins play game.”

Data Security

Nobody wants to show up and in tomorrow’s Wall Street Journal. In the current day and age, there’s an entire team dedicated just so that that payer’s name doesn’t show up on tomorrow’s newspaper. Primarily because with the PHI (Protected Health Information), the abundance of PHI information from all different sources. It’s extremely important to say: “Well how do we protect our data?” Payers have a lot more data than anybody else outside of providers.

And there are two different spectrums of the data set – and both are equally critical from the standpoint of ensuring that data security is a key aspect in your space because today, a 100 record, 500 records, or anything above that threshold you’re going to have to report it. So, data security becomes actual strategy nowadays. How do you make sure that your data security is actually playing to your advantage? And your customers have to be able to trust that and that Trust is what’s going to actually give you – even though that has nothing to do with the actual health plan itself, or the benefits members are receiving, or the card that they are receiving. But they still have to be able to trust that their data is secure. 

Showing Value Vital in Provider/Hospital Negotiations [10:17]

Finally, when it comes to providing the value of data, the data set that payers are actually having to wrestle with: how are we showing the value that we are providing to the hospital segment, the provider segment, and the member segment? 

But if you look at it, you still have to deal with all the other aspects before you get to the value component: administrative setup, data security, operating margins, and everything.Contract negotiations. HealthCare Executive Group. Benefits Costs. Patient Outcomes. Quality Standards. STAR ratings. Profit Margins. Improving Efficiencies. EQ Health Solutions. Solving the Rubik’s Cube of Payer Data. Health Plans. Payer market. evaluating healthcare analytics vendor. Data Security. Tools and Technologies.Well, how is that actually happening? Big data. Well, I’m not going to bore everybody with the definition of what big data is but, in a nutshell, in today’s world of Instagram, Facebook and Snapchat it’s all about the volume and speed and the frequency of the data that you’re receiving. And in the payer market, it’s a lot of data. It used to be a monthly fee [to obtain/access data]. Now it’s an API call to an HL7 message which is instantaneous. And the amount of frequency that you’re having to deal with is a lot more than what you had before. And the number of types of data that the payer market is actually having to deal with is a lot more. And even in there, the data can be segregated into a couple of different ways: 

  • The data that’s the primary data sources
  • The derived data sources that you’re generating as a result of your operation or as a result of some of the analysis that you’re doing on top of it. 

So now that’s another big trend that the payer market is having to actually wrestle with.

Social Determinants of Health Data are Increasingly Important

Ferris Taylor [HCEG’s Executive Director] indicated that this [Data & Analytics] was the top topic and social determinants of health were one of the key aspects to it. And that hasn’t changed. What has changed is how that’s being viewed. Instead of being a peripheral data source to actually being a central component to how your operations need to be done from social terms of health standpoint.

Marina Brown, EQHealth’s Vice President of Clinical Programs added:

I was just going to say that I do think that this is really a big one for the industry. Social determinants of health are definitely going to help change the way that we deliver health care. And that’s a very important distinguishment. It’s not going to change the way that we do health care because we treat a diabetic the same but it will change the way that we deliver care simply by helping to better guide the interventions that we’re utilizing to create more meaningful behavior change over time.

Tools and Technologies to Solve the Rubik’s Cube of Payer Data

Marina and Mayur shared an overview of the tools and technologies that healthcare payers are using to identify trends, root causes of patient and population-level issues, and transforming healthcare payer’s data and analytics infrastructure.

Another key aspect is artificial intelligence. Now again I don’t want to get into the definitions of artificial intelligence, but the key aspect is, with the advent of big data with the advent of the amount of data you’re having to deal with. It’s not humanly possible for a supervisor or a manager or a management team to be able to simulate all the data and actually say: What am I making use of this data? And how am I going to make use of this data? And what decisions am I making?

So artificial intelligence – or machine learning – and they’re not necessarily synonymous but in some in some aspect they’re synonymous in terms of combining the wealth of data that you’re getting and actually seeing what insights can be derived based on all those data sets; at a much more faster pace and a more timely manner compared to what we would have had to do if we were doing it manually. And there is an element of: how do we use the machine learning algorithms or artificial intelligence approaches to say: Can I do a better prognosis?

Everybody’s aware of [IBM] Watson’s cancer cure approaches to it and Watson has evolved a lot of other stuff. But predominantly in the mainstream the payer market, this hasn’t yet taken off into a full-fledged problem because we’re dealing with not necessarily a literature research but more in the realm of operational research and operational analytics.

Hear more from Mayur and Marina about tools and technologies at [13:09] and [24:53] in the recording.Artificial Intelligence. Predictive Analytics. Bigdata. Machine Learning. HealthCare Executive Group. Benefits Costs. Patient Outcomes. Quality Standards. STAR ratings. Profit Margins. Improving Efficiencies. EQ Health Solutions. Solving the Rubik’s Cube of Payer Data.

How can we employ artificial intelligence or machine learning concepts into the operational realm of the payer operation? [14:40]

There are some positive trends. There’s a huge growth of Medicare Advantage (MA) plans. Their margins continue to increase because it’s a catch-22 situation for MA plans because of the risks. And now MA plans are able to accurately reflect their risk scores. And as a result, their premiums are being reflected the right way – which actually helped them from their margin standpoint because their operations were still on the same aspects of it because in the previous era they were not reporting their risk the right way because they didn’t have all the data gathering up opportunities. But now that they’re able to gather their [data analysis] opportunities, they can predict their risk a lot more accurately, so their premiums are going up. As a result, the margins are getting better and also the operations have stayed the same.

Government Plans Off-Loading Operational Functions to Health Plans

And in the Medicaid managed care space what you’re seeing is a lot more growth in that space for, predominantly, what we could say s for one single reason: most of the state administrative entities are actually trying to off-load the burden onto the plans so that risk is being passed on to the managed care plans and the state entities become the administrative agency. Of course, with that, they’re also holding performance measures as an accountability which is not just about the financial side of it but also the quality side of it because they don’t want to sacrifice the quality of care being rendered to their beneficiaries. But as a result, you’re seeing a lot of growth in the managed care space Medicaid managed care well

What does this mean to me or my organization as a payer? [16:29]

If I actually eliminate all the big terminology, fundamentally there are two simple concepts:

  1. Is our plan performing better than what it was before from a cost standpoint? And with the qualifier added, is the plan performing to a level where the plan can afford too? Because one of which you’re collecting to your risk is what you’re paying out. That’s one of the key foundations. That’s a simple question that you’re going to answer.

And the second aspect of it is:

  1. Are we improving the quality of our plan? And quality can be defined in multiple ways. I think the STAR rating, the HEDIS measures, and all that stuff. But at the end of the day it’s really are you improving quality in terms of outcomes for the members?

And the second point is actually impacting the first point from a long-term standpoint. So, if you’re impacting the quality aspects of it, then you’re able to impact the cost aspect of it as well. But it doesn’t happen every year, it happens over as a strategic view. You have to put that as a strategic view long term view so that on the short run your cost structure might have variances but over a long run, you’re actually improving the trends of that one.Rubik’s Cube of Payer Data. Artificial Intelligence. Predictive Analytics. Bigdata. Machine Learning. HealthCare Executive Group. Benefits Costs. Patient Outcomes. Quality Standards. STAR ratings. Profit Margins. Improving Efficiencies. EQ Health Solutions. Solving the Rubik’s Cube of Payer Data. Health Plans. Payer market. evaluating healthcare analytics vendor. Data Security. Tools and Technologies.

Operational Simplicity and the Health of Your Health Plan [17:54]

But what does that mean in terms of a payer when you think about how you have to think about it?

It comes down to two things: operational efficiency and health of your health plan. How do we make a difference in looking at all the data that we have and actually answer these two business questions; and then tie them back to the simple questions of ‘Am I performing better in terms of cost?’ And ‘Am I improving the cost?’

Marina added: [18:38]

I think that operationally looking at the data is really going to, as a program administrator, is going to give me insight into things like the following:

  • What care management programs or medical management programs are most needed for my population?
  • What programs that I’m currently utilizing are really the most effective ones?

Taking that a step farther as you look into those specific programs that are most effective, you’ll also then be able to look at things like: What are the interventions that are most effective in this population. From a utilization review perspective?

Is my UR working only as a gatekeeper for my health plan or are we actually effectively managing acute episodes and beyond that acute episodes? And then really helping us determine all of this ultimately helps us determine what care intervention strategies do we need to tweak? Which ones do we need to add to our programs to create that meaningful behavior change that increases the health of our membership, increases the quality of the care that’s being provided to that membership, and ultimately reduces the cost?

The Rubik’s Cube of Payer Data – the Present Debacle

Mayur shared some insight into the struggle that many payers have regarding reporting and analytics: [20:03]

In a lot of ways, payers are struggling between: Am I doing reporting or am I doing an analysis? And how am I looking at it? Am I doing the analysis for the sake of reporting or am I doing analysis for the sake of improving or answering the two questions that we started out with?

  1. Is our plan performing better than what it was before from a cost standpoint?
  2. Are we improving the quality of our plan?

HealthCare Executive Group. Benefits Costs. Patient Outcomes. Quality Standards. STAR ratings. Profit Margins. Improving Efficiencies. EQ Health Solutions. Solving the Rubik’s Cube of Payer Data. Health Plans. Payer market. evaluating healthcare analytics vendor. Data Security. Tools and Technologies.And those could be the patient member outcomes, quality standards, STAR ratings, keeping benefits cost down, maintaining the profit margin, improving efficiencies. All of these are questions that every payer is asking.

And the list goes on and on and you guys are actually dealing with a lot more in today’s world. I’m sure every organization has a ton more questions to add to it but, fundamentally, why and how to do it is where the biggest question comes into play because often everybody goes down the path of: ‘Okay, I need to solve this reporting problem so I need to have this kind of technology in place. I need to solve my data analysis problem from a predictive modeling standpoint, so I need to have this technology base.

And as a result, you’re creating more and more silos within the analytic space and not necessarily taking advantage of the full spectrum of the data that you have or creating in its entirety in a holistic view. Because at the end of the day, if the technology analytics is being used for the reporting purposes then you only solve 30% of your problems because the majority of your problems are deriving insights from your data and actually saying how can we make a difference in our operations? How can we make a difference in our outcomes?

Payers have multiple data sources and everything is often viewed as a silo. [23:30]

Healthcare organizations are maturing but fundamentally they’re still struggling with the aspects of:

  • Am I doing quality analysis?
  • Am I doing financial analysis?
  • Am I doing operational analysis?
  • Or am I doing just reporting for the regulatory agencies?

Payers need to design their operational strategy to leverage all quadrants of dimensions: Quality, Financials, Operations, and Predictive Analytics.

Marrying Clinical Expertise with Data Analytic Capabilities [25:04]

HealthCare Executive Group Top 10 list. EQ Health Solutions. Solving the Rubik’s Cube of Payer Data. Health Plans. Payer market. evaluating healthcare analytics vendor. Data Security. Tools and Technologies.

I want to talk briefly about the key components that are going to make a difference. Often what happens is an analyst is asked a question and they actually come back and that data set is then presented to clinical leadership. And then clinical leadership asks a follow-up question and then makes some decisions on top of it. But in reality, what if you change that and involve that clinician up front during the analysis itself, along with the data scientist? So, what we view in the industry is that there’s a lot more benefit if you actually pair the clinicians and the data scientists together up front in the design and analysis phase.

So that 1) you can cut down your cycle crime and 2) you’re asking the questions up front and how to think about your operations. And that’s going to help frame your reporting and analytics problem in a way where you’re getting to a solution much faster.

Marina added:

I think that’s a really important point that you’re making. I think bringing these two teams of people together helps to bring about that important balance and maximize your outputs because your data scientists are experts at identifying the trends and the data. And when that information is presented to the clinicians, they can then help interpret those trends. That’s going to ultimately formulate your adjustments to your operations, your program design, etc. I think that’s a great point.

Pairing Clinicians with Data Scientists Frees Up Time for Patient Engagement

Mayur continued:

And another aspect to it is, when you’re thinking for clinicians, you’re actually taking away their valuable time working with a member. If you’re asking them to understand what’s happening with the data and go into the exercise and then making the decision to it. But if you pair them up front, you’ve solved the problem and then you’re giving them time to have their team’s focus more on the members then they are focusing on the data itself.

Marina added:

Right. Care teams are so busy trying to make that outreach to the members that having that technology available to them, to be able to guide them to identify trends or issues with that particular member, is going to save time. And it ensures too that all of the important or pertinent trends for that particular member, for that particular population, are being identified. Because at the end of the day, clinicians are just that, clinicians. They’re not data analysts.

Developing a Multi-Dimensional, 360-Degree View of Your Data

Marina and Mayur presented some insight and ideas on how to create a decision-making framework providing a multi-dimensional, 360-degree view for your clinical, operational, administrative, and financial teams.

See [28:15] for more information, insight, and ideas on creating a multi-dimensional, 360-degree view of your clinical, operational, administrative, and financial data.

Top Six Things to Consider When Evaluating Healthcare Analytics Vendors

Here are top six things that you should consider when you think about analytics or in the majority of organization’s how you want to get there.

  1. Data Security
  2. In-House Experts
  3. Intuitive Easy-To-Use Platform
  4. Actionable Real-Time Data Visualization
  5. Data Accuracy
  6. Acceptance of Data in Any Format

For details on the importance of each of the above considerations for evaluating healthcare analytics vendors, listen in starting at [36:04].

Questions from Webinar Series Attendees

Our organization currently executes minimal analytical formalities, processes, etc and we are at an immature analytical state. Would investing and working with an analytics vendor refute all [our efforts] at this stage in our organization? [44:37]

Mayur: No. You can view it from the standpoint of: if you’re in the early stages of maturity then that would be the perfect time to assess how you want to design your system and what kind of systems you want to have in place. And you may not have to go through the same evolution steps that the entities started out early on. You may actually leapfrog by taking in all that stuff up front itself. So absolutely, even if you don’t have all the data organized in a unified view that’s fine too because you do have data sets. The first steps very well could be how do you get them into the unified view. So I wouldn’t hesitate working with and investing in analytics if you’re in the early stages of maturity because this very well could be an opportunity where you don’t have to redo the some of the things that you might have done if you’re already in further stages.Artificial Intelligence. Predictive Analytics. Bigdata. Machine Learning. HealthCare Executive Group. Benefits Costs. Patient Outcomes. Quality Standards. STAR ratings. Profit Margins. Improving Efficiencies. EQ Health Solutions. Solving the Rubik’s Cube of Payer Data. Health Plans. Payer market. evaluating healthcare analytics vendor. Data Security. Tools and Technologies.

Our organization prides itself on taking the best care of our patients. Can you give us examples of how using an analytics vendor can improve our patient outcomes vs. just us monitoring it internally? [46:03]

Marina responded to this question with an interesting story about how EQ health identified and assisted high-utilization, low literacy, diabetic patients in the Mississippi Delta.  Listen at [46:22] as to how EQHealth made life easier for patients and improved their health, all while reducing emergency room visits and inpatient admissions.

My team is discussing the decision to build an analytics platform internally or buy and outsource it with a vendor. Do you have any insight into what is more successful and pros and cons? [50:50]

Mayur: I don’t think there is a right answer or wrong answer. It really centers on your strategy. Are you trying to make that as your core competency or are you wanting to retain your core competency to manage plan operations but want to have the benefit of the analytics and the analytics platform; then at that point you should outsource. But if you’re wanting to make analytics your core competency, then you need to have that in-house. But when you do decide to make it in-house, you still need to… hear the rest of Mayur’s answer at [51:08]

Listen to more questions and answers from Solving the Rubik’s Cube of Payer Data here.

More Insight for Healthcare Leaders

Our Webinar Series events are one example of how the HealthCare Executive Group helps to share information and promote collaboration between our members, associates and sponsor partners. Our next Webinar Series event will be ‘Using People, Process & Technology to Grow Your Business’ and will be presented by our sponsor partner HealthEdge on July 25th, 2019 at 2:00 pm ET.HCEG. HealthCare Executive Group Webinar Series: ‘Using People, Process & Technology to Grow Your Business’ HealthEdge.

HCEG’s 2019 Annual Forum

Save The Date HCEG Annual Forum

In addition to connecting with us on Twitter and LinkedIn and subscribing to our eNewsletter, consider joining other healthcare executives and industry thought leaders at our 2019 Annual Forum in Boston, MA on September 9-11, 2019. In addition to the always insightful, information-packed sessions and networking opportunities our annual forum offers, we’re including two special networking events on Monday, September 9th:

  • Tour of the IBM Watson Research Facility in the morning
  • Red Sox vs. Yankees Baseball Game at Fenway Park in the evening

For more information, click here and/or contact us at [email protected].

Part 2 of Health System & Health Plan Innovation, Change & Growth During Uncertain Times

By | AHIP, Health Literacy, Healthcare Policy, Payers, Waste & Abuse | No Comments

health systems health plans focus for 2017 health reform outcome literacy members consumers #HITsmIn Part 1 of this series of posts, we shared some insight, ideas and opinions on the first of six topics shared in last week’s Health Information Technology Social Media (#HITsm) tweetchat Health System & Health Plan Innovation, Change & Growth During Uncertain Times.” A total of 72 participants tweeted over 650 times in the chat co-hosted by the Healthcare Executive Group, @_GWConnect and @_GuideWell.

In this second post, select insight, ideas, comments and opinions on Topic #2: What must health systems & health plans focus on over next 8 to 18 months regardless of health reform outcome? are shared. The remaining topics will be addressed in future posts.

Insight, Ideas and Opinions on Topic #2

Connect with Members, Consumers & Patients

  1. Create a connection with the patient that goes beyond the office visit.
  2. Identify, understand & work with ‘impactable members’ to help them make good, cost-effective decisions about their healthcare.
  3. Health systems & plans need to engage w/ patients & members on a more meaningful & regular basis. Not just via EOB’s.
  4. Find out what’s going on in patients’ homes and determine the services they need to keep them healthy.
  5. Include the patient in everything – from the patient’s own care to the growth of the health plan/system. Act on what they hear.
  6. This’s the ‘Hatched, Matched & Dispatched’ cycle. Health plans only ‘engage’ at enrollment, w/ claim EOB’s & at termination.

Address Waste & Abuse

  1. At #AHIPInstitute, Eric Topol said ‘75% of top 10 high cost drugs are prescribed to non-responding patients.” STOP the waste!
  2. Waste and overtreatment, heard from @DocLazris #ErikRifkin are on a mission against it. Video here:
  3. IMHO it’s important to educate people about how to use their insurance effectively to control their costs. Price Transparency too

Help Consumers Become Better Patients

  1. Focus must be on enable patients to take control of their own care and to be more involved through easy integration of tech.
  2. Universal language – like, “Do you accept my health plan?” Simple question but so often answered wrong.
  3. When these languages are translated into HIT, all those stakeholders interpret associated rules & allowances differently
  4. If you adopt universal languages, IMHO, you will see some of these issues disappear or at least some clarity enter
  5. Smaller, more often, more meaningful. I have to write stuff that’s specific, timely, and actionable – why does H/C bury me in dross?
  6. Anthem has a monthly health plan summary to members that contains ‘personalized and actionable’ health & wellness insights.
  7. “Self-Care Shows Promise In Keeping Individuals w/ Behavioral Health Needs Out of the ER” – Video here:

Don’t Ignore the Masses – Invest in Preventive Services

  1. Insurance! Invest now to save later is a motto that not many want to hear but need to have more faith in.
  2. Need to focus on treating the largely ignored ‘healthy people’ to prevent them from becoming the 5% of patients consuming 22%
  3. I am going 2 go there. Inclusion. No high risk pools. The One-Plan Plan. With a focus on prevention and wellness to mitigate risk
  4. We need to start providing preventive treatments to the masses vs. spending lion’s share of resources on the few sick.
  5. Such a good question. I think prevention costs are minimal compared to the other side of heart surgeries or chemo…
  6. I know a plan that’s feeding care gaps to physicians, so they can stay ahead of the gaps. Also helps scheduling.

Focus on Core Mission & Quality

  1. Shedding/outsourcing operations not core to their mission – like moving data centers to the cloud are long overdue.
  2. All #healthcare needs to focus on quality of care, especially since value-based care and payments look like they will stay

Smartphones – Everyone Has One – Leverage Them!

  1. IMO, health systems & plans must enable consumers and patients to use those things they’re always staring at: Smartphones.
  2. Our President Dr Rene Lerer suggests smartphones will be the “most important part of your body” for health


  1. No matter the #ACA result, plans and providers must get along, and have systems/infrastructure to enable real-time data exchange.
  2. Also interoperability among healthcare tech platforms to provide better utilization of collected patient data

More on the Remaining Four Topics Coming Soon

Check back later this coming week to learn what chat participants shared on the remaining four topics:
      T3: Who’s most likely to disrupt healthcare: insiders or outsiders? And what barriers do each face – right now or in near future?
      T4: What technologies will do the most to move healthcare supply-side toward improving outcomes, lowering costs & enhancing equity?
      T5: Incentives drive innovation. How can they be aligned to meaningfully support innovation that improves outcomes & lowers costs?
      Bonus: What are examples of innovative healthcare programs, processes, people and organizations – U.S.-based or elsewhere?

One More Time!

Thanks again to our co-hosts @_GWConnect and @_GuideWell, John Lynn (aka. @TechGuy) of Healthcare Scene and to all those who participated in the chat.  A complete transcript of the chat can be found here.

For more about opportunities, challenges, and issues impacting healthcare plans, health systems and payers, consider following @HCExecGroup on Twitter and join us on LinkedIn and Facebook too.

Health System & Health Plan Innovation, Change & Growth During Uncertain Times – Part 1

By | AHIP, Healthcare Policy, Holistic Individual Health, Payers, Quality Measures | No Comments


Last week’s Health Information Technology Social Media (#HITsm) tweetchat was co-hosted by the Healthcare Executive Group, GuideWell and GuideWell Connect from the 2017 AHIP Institute & Exhibition in Austin, TX.

The theme of the chat was “Health System & Health Plan Innovation, Change & Growth During Uncertain Times” and following six topics were discussed:

T1: What specific ‘areas of opportunity’ must health plans/systems address to improve health outcomes, lower costs & improve equity?
T2: What must health systems & health plans focus on over next 8 to 18 months regardless of health reform outcome?
T3: Who’s most likely to disrupt healthcare: insiders or outsiders? And what barriers do each face – right now or in near future?
T4: What technologies will do the most to move healthcare supply-side toward improving outcomes, lowering costs & enhancing equity?
T5: Incentives drive innovation. How can they be aligned to meaningfully support innovation that improves outcomes & lowers costs?
Bonus: What are examples of innovative healthcare programs, processes, people and organizations – U.S.-based or elsewhere?

Thanks to Hosts & Participants!

Special thanks to John Lynn (@TechGuy) of Healthcare Scene, our co-hosts @_GWConnect and @_GuideWell and all the 70+ who participated in the chat.  A complete transcript of the chat can be found here.

Insight, Ideas and Opinions on Topic #1

This post shares insight, ideas and opinions shared by #HITsm chat participants on Topic #1. We’ll share more on the other topics in future blog posts.

Precision Medicine – aka. Personalized Medicine

  1. Precision medicine (aka ‘personalized medicine) was a hot topic at this week’s #AHIPInstitute in Austin.
  2. Patients with complex needs require a custom approach. Personalized medicine promises to improve outcomes at lower cost.
  3. Be excited when we get to the point where #AI effective for health plans. We’re still collectively digging for gold in claims data.
  4. Implementing positive changes in the healthcare industry that give clinicians the opportunity to view #PatientCare in a new light
  5. We definitely need this for #UX — the difference b/t changing your bank profile and your payer profile is enormous

Patients, Consumers & Health Plan Members

  1. It wasn’t that long ago that HC plan leaders were saying “HC plan members aren’t consumers,” LOL
  2. Addressing the healthcare needs of the #aging population of the country will need to take a seat in the front row
  3. Taking advantage of the data we are given to visualize the patient condition and identify at-risk patients earlier
  4. Getting members engaged and empowered in understanding, maintaining, and improving their own health journey
  5. Consumerism has been making inroads into healthcare, patients are acting like consumers about their healthcare options
  6. Until patients “get it” health outcomes can only improve so much

Importance of Basic Health Education, Literacy & Preventive Care

  1. Improving basic health education & literacy through active & coordinated outreach to members & patients is a big opportunity
  2. Improving education & literacy can be as simple as adopting universal languages so plan members aren’t constantly confused
  3. More focus to prevention & wellness. Reach patients before they get ill or have a major medical event.
  4. We need to focus more on prevention – spending too much on too few people – and often late in life.

Customer Relationship Management

  1. Customer service is an area of opportunity, healthcare needs to accept the change and adapt accordingly
  2. Before the healthcare industry dives into AI – they should incorporate basic CRM functions into #EHR systems. Huge communication disconnect!
  3. Addressing the need for clinical decision support and getting the right information available at the right time

Data is Critical to Healthcare

  1. Challenge w/ personalized medicine starts w/ lack of ability to accurately identify correct patient some crazy % of time…
  2. And, of course, standardizing data (#interoperability) to encourage cooperation between all #healthcare entities
  3. Systems that can use unstructured data to inform decisions. AI and machine learning?
  4. Real-time data sharing, especially clinical data, with providers and especially patients
  5. Absolutely! RTI approach needs to be incorporated from data driven perspective
  6. Systems need 2 embrace outcome-driven & SDOH/BDOH-driven ops to lower costs & affect outcomes. Walk the walk; we’ve heard the talk

The Importance of Home & Social Determinants of Health

  1. Health data taken from the home of the patient using this technology can be shown to doctors for perhaps better, tailored care
  2. Another area to take advantage of is using technology to bring healthcare to the home of patients.
  3. It is the space between heart beats where we live – IE not an “area” but care coordination between areas and with patients

Quality Measures & Measuring Outcomes

  1. How about better assessment & collection of what matters to members/patients? Instead of fancy analytics from quants?
  2. How do we measure feelings and happiness? Or are outcomes more quantifiable?
  3. System wide outcome driven treatment and outcome measures to tailor individual client centered care. Educate for prevention
  4. Analytics allows for effective clinical assessments by providing better patient outcomes
  5. We’re trying to do this now, in way, with HCAHPS/CAHPS, right? Don’t believe currently effective, but CAN be quantified.
  6. Do you see a worthwhile set of quality measures worth aligning to?
  7. Great idea: patient-centric measures. What outcomes do patients/members want to achieve, and what data do we need to drive them?
  8. We do this in OT for quality of life/ perceived ‘happiness’ with what is most valuable. All valid reliable and evidence based measure

Look for More on the Other Topics in Following Posts

Check back for more insight, ideas and opinions from the #HITsm chat. Thanks again to John Lynn and our co-hosts @_GWConnect and @_GuideWell and all those who participated in the chat.  A complete transcript of the chat can be found here. You can also follow @HCExecGroup to learn more about opportunities, challenges, and issues impacting healthcare plans, health systems and payers.

Highlights from Day 1 of 2017 AHIP National Health Policy Conference

By | AHIP, Delivery System Transformation, Healthcare Policy, Next Generation Payment Models, Payers, Value-Based Payment/Care | No Comments

The 2017 AHIP National Health Policy Conference kicked off today in Washington, DC.

Political, business, and health care leaders from across the nation gathered to dive deeply into our nation’s top policy priorities in an effort to move forward in today’s uncertain healthcare environment.

What a period for healthcare reform in the United States!

In addition to some general comments about healthcare policy and politics, today’s sessions addressed topics such as the following:

  • Risk-sharing and Cost Control
  • Value-based Care
  • Pharmacy Costs
  • Medicaid Exchanges
  • Importance of Social Determinants of Health

Social shares from conference attendees

As is happening more and more at many of today’s top healthcare conferences, conference proceedings, insights and other information were shared on Twitter – among other social channels. Here’s a sample of some interesting shares from Day 1 of the 2017 AHIP National Health Policy Conference.

Thanks to all those noted below who took the time to share with those who were unable to attend the conference.

General Stuff

Handle Tweet
@ajmc_journal There’s still a basic misunderstanding of how health insurance works, says @AHIPCoverage’s Tavenner
@rpalme01 @MD_Insurance @al_redmer ACA “status quo is not an option, status quo is not a solution”  #ACA
@nancyrwise Newt Gingrich sure that SOME bill will be passed this session…  but no direction on what it will include.  #AHCA
@nancyrwise T. Nickel, thank you: “Association Health Plans are awesome… until they are not”  @NAIC_News

Cost of Healthcare & Risk-Sharing

Handle Tweet
@ajmc_journal The only cost containment strategy that works is cost sharing but it can be such a burden that it takes care away–@chipkahn
@avercloud Healthcare payers: Make the move from pilot to full-scale bundled payment adoption. Let’s discuss at #AHIPPolicy
@leah_a_brown The discussion a few years ago was about coverage, now healthcare 2.0 is about cost.
@mahphealth Good point by MD Comm. Al Redmer Jr on NAIC panel Can’t do anything on premiums unless moderate cost of delivering #healthcare
@nancyrwise Great quote: “Pay for value = transferring risk to providers.” M. Chernew
@nancyrwise If health orgs are bigger & more integrated, they are better positioned to own market power: unlikely to lower costs. M. Chernew
@suemontgomery2 Cost of premiums is all about the cost of delivering care. – Ted Nickel at #AHIPPolicy

Value-based Care & Reimbursement

Handle Tweet
@ahipcoverage Consumers want affordable coverage & high-quality care – that’s what value-based care delivers.
@avercloud Debate the policy, but value-based healthcare is here to stay. Let’s discuss bundled payment success at upcoming #AHIPPolicy


Handle Tweet
@springstex Prescription drug costs pass physician services as biggest slice of health insurance premium
@rpalme01 Keep talking to your local pharmacist and sharing what he tells you.

Medicaid Exchanges, Access & Importance of Social Determinants of Health

Handle Tweet
@ajmc_journal Healthcare reform is a question of access vs true availability. The devil is truly in the details, said @AndyGurmanMD
@nancyrwise Interested in continuing conversations about potential intersection of #Medicaid and Exchange markets in #healthcare #simplicity
@ahipcoverage From transportation, housing & environmental health, plans are addressing social determinants of health

Keep on Top of More Insight on Healthcare Reform

Be sure to follow the Healthcare Executive Group on Twitter, Facebook and LinkedIn where we share insight into the challenges, opportunities and issues facing healthcare executives and others in today’s fast-changing healthcare environment.

How Predictions About Healthcare in 2017 Compare to HCEG Top 10 List

By | Data & Analytics, HCEG Top 10, Payers | No Comments

2017 Healthcare Predictions HCEG

It’s that time of year when everyone is sharing their thoughts on healthcare predictions and trends for 2017. And the Healthcare Executive Group wants to take this opportunity to share what it considered the Top 10 Priorities, Issues and Challenges facing healthcare supply-side constituents: health plans, payers, providers and health systems.

History of HCEG Top 10 List

The HCEG Top 10 list of Healthcare Priorities, Issues and Challenges has been a pillar of the Healthcare Executive Group for the last 12 years. The list is developed each year during HCEG’s annual forum and reflects what HCEG healthcare executive members think will be their primary focus for the following year.

The HCEG Top 10 list for 2017 includes the following items:

  1. Value-based Payments: targeting specific medical conditions to manage cost and quality of care
  2. Total Consumer Health: improving member’s overall well-being – medical, social, financial, and environmental
  3. Clinical and Data Analytics: leveraging big data with clinical evidence to segment populations, manage health and drive decisions
  4. Cybersecurity: protecting the privacy and security of consumer information
  5. Cost Transparency: growing legislation and consumer demand
  6. Harnessing Mobile Health Technology: improving disease management, member engagement, and data collection/distribution
  7. Addressing Pharmacy Costs: implementing strategies to address growth of pharma costs versus benefits to quality of care and total medical costs
  8. Care Redesign: leveraging team-based care models, focusing on behavioral health and social needs
  9. Accessible Points of Care: telehealth, retail clinics and micro-hospitals vs. large, integrated systems
  10. Next Generation ACOs: additional programs in bundled payment, episodes of care-shared savings, and growing participant base

To be sure, the items on the HCEG Top 10 list may not be considered predictions as much as they are ‘important areas for those on healthcare’s supply side to be aware of in 2017.’

“It’s tough to make predictions, especially about the future” – Yogi Berra

And it’s not just HCEG members who compile lists of predictions and trends for the healthcare industry. In the waning weeks of the year, industry professionals, health plan and hospital system CEO’s, leading consulting firms like PWC and Accenture, research firms like Gartner, media reporters, and a host of others all share their take on what they consider to be important trends and predictions for the upcoming year. Here’s a list of some of those sharing their 2017 Healthcare Predictions.

Given the ubiquity of “predictions for healthcare in 2017” and the fact that healthcare was a primary issue in the U.S. presidential election, it seemed that comparing HCEG ‘s Top 10 list to the summarized results of 2017 healthcare predictions made by others would confirm HCEG’s list and/or call out differences. The fact that the HCEG Top 10 list was compiled BEFORE the presidential election and all of the comparison lists were created AFTER the election is envisioned to, at least somewhat, account for any impact the election may have had on people’s interpretation of priority and value.

Collection of Predictions about Healthcare & Healthcare Technology in 2017

To establish a baseline list of predictions and trends for healthcare in 2017, the lists contained in this blog post were reviewed with categorized based on their primary and secondary categories with the results compared to the items on the HCEG Top 10 list. A few facts and observations about this baseline list:

  1. 36 lists containing a total of 179 “predictions” were curated
    HCEG 2017 Predictions - Major Categories

    HCEG 2017 Predictions – Major Categories

  2. Only predictions that were clearly understood and of sufficient granularity were included
  3. Each prediction was coded with one of the following 19 primary categories
  4. Where possible, a secondary category was assigned

Analysis of 2017 Predictions

Most Frequently Referenced Categories

In terms of most frequently referenced predictions (regardless as too rank) found among the 30 lists reviewed, Emerging Technologies, Reform/Regulations, Analytics & Big Data, Value-based Reimbursement, Access, and Consumerism were among the most frequently cited areas of focus in 2017.

Category Count Corresponding HCEG Top 10 Item(s)
Emerging Technologies 29 6-Harnessing Mobile Technology
Reform/Regulations 24 8-Care Redesign (loose correlation)
Analytics & Big Data 19 3-Clinical and Data Analytics
Value-Based Reimbursement 16 1-Value-based Payments

5-Cost Transparency

Access 13 9-Accessible Points of Care
Consumerism 11 2-Total Consumer Health
Interoperability 9
Finance/Reimbursement 9 1-Value-based Payments

5-Cost Transparency

7-Addressing Pharmacy Costs

Cybersecurity 8 4-Cybersecurity
Mobile Health 6 6-Harnessing Mobile Technology
Processing Efficiency 6
Digital Transformation 5 6-Harnessing Mobile Technology
Collaboration 5 10-Next Generation ACOs
Mergers & Acquisitions 4
Health Literacy 4 2-Total Consumer Health

5-Cost Transparency

Pharmacy 3 7-Addressing Pharmacy Costs
Resources 3
Precision Medicine 2 8-Care Redesign
Wearables 2 6-Harnessing Mobile Technology
Patient Experience 1 2-Total Consumer Health

9-Accessible Points of Care

Categories by Top 3 Rankings

In an attempt to present the data in a more generalized fashion, the following table reflects the ranking of the categories based on the sum of the top three rankings for each item.

Category Count Top 3 Count Top 3 % of Count Corresponding HCEG Top 10 Item(s)
Reform/Regulations 24 15 63% 8-Care Redesign (loose correlation)
Emerging Technologies 29 14 48% 6-Harnessing Mobile Technology
Analytics/Big Data 19 12 63% 3-Clinical and Data Analytics
Consumerism 11 8 73% 2-Total Consumer Health

5-Cost Transparency

Access 13 7 54% 9-Accessible Points of Care
Value-based Care 16 7 44% 1-Value-based Payments

5-Cost Transparency

Cybersecurity 8 6 75% 4-Cybersecurity
Finance/Reimbursement 9 6 67% 1-Value-based Payments

5-Cost Transparency

7-Addressing Pharmacy Costs

Mobile Health 6 6 100% 6-Harnessing Mobile Technology
Collaboration 5 5 100% 10-Next Generation ACOs
Digital Transformation 5 5 100% 6-Harnessing Mobile Technology
Interoperability 9 5 56%
Processing Efficiency 6 5 83%
Health Literacy 4 3 75% 2-Total Consumer Health
Mergers & Acquisitions 4 3 75%
Pharmacy 3 3 100% 7-Addressing Pharmacy Costs
Resources 3 3 100%

Insights on How HCEG List Compares to General 2017 Predictions

While certainly subject to some interpretation and discussion, the following four areas listed by many of those sharing their 2017 Predictions were NOT directly matched to any of the items on HCEG’s Top 10 list.

Category Prediction from Article
  • Acceleration of Interoperability
  • EHR access
  • Financially stable, regional IDNs are spending big dollars toward extended connectivity while rest of the pack looks on
  • Integrated systems
  • Integration of medical & social determinants of health
  • Interoperability: Continuing progress
  • More progress and collaboration around interoperability
  • Organizations choosing platforms vs. application silos will only accelerate
Processing Efficiency
  • $1 of innovation will need $7 of core execution
  • Adoption of auto-adjudication will accelerate
  • Auto-adjudication will drive providers to interact with EHRs, revenue cycle management and practice management vendors.
  • Complex claims outsourcing market grows
  • Cost reduction pressures require balance with compliance demands
  • Focus on front end and middle office business office functions & RCM outsourcing intensifies.
  • Consolidation of activities to Top 7 Digital Giants
  • Continued growth of merger and acquisitions as the reimbursement mechanisms favor organized groups of providers.
  • Many more insurers will drop out of the marketplaces.
  • Maturation of digital health startups and increasing merger and acquisition activity
  • Human resources shortage
  • Skilled hospital tech staff recruitment is even more challenging.
  • The rise of non-CIO executives in technology decisions: Not quite yet

Note: Items in above table were culled from various articles listing 2017 Predictions. 

Overall Rankings of 2017 Predictions

The following major categories of 2017 Healthcare Predictions are based on the rank assignments as noted by the author of each of the individual articles/posts.

#1 Ranking 36 % of Ttl #4 Ranking 22 % of Ttl
Reform/Regulations 7 19% Value-Based Care 5 23%
Emerging Technologies 4 11% Analytics/Big Data 4 18%
Value-Based Care 4 11% Reform/Regulations 3 14%
Cybersecurity 4 11% Interoperability 2 9%
Finance/Reimbursement 3 8% Access 2 9%
Analytics/Big Data 3 8%
Consumerism 3 8% #5 Ranking 17 % of Ttl
Emerging Technologies 4 24%
#2 Ranking 34 % of Ttl Value-Based Care 2 12%
Analytics/Big Data 6 18% Processing Efficiency 2 12%
Emerging Technologies 5 15%
Reform/Regulations 5 15% #6 Ranking 12 % of Ttl
Digital Transformation 3 9% Access 2 17%
Consumerism 2 6% Emerging Technologies 2 17%
Finance/Reimbursement 2 6% Reform/Regulations 2 17%
Processing Efficiency 2 6%
Mobile Health 2 6% #7 Ranking 11 % of Ttl
Emerging Technologies 3 27%
#3 Ranking 31 % of Ttl Reform/Regulations 2 18%
Emerging Technologies 5 16% Analytics/Big Data 1 9%
Access 5 16%
Mobile Health 3 10% #8 Ranking 6 % of Ttl
Analytics/Big Data 3 10% Emerging Technologies 3 50%
Consumerism 3 10% Resources 1 17%
Reform/Regulations 3 10% Consumerism 1 17%

Note: Some lists didn’t explicitly rank their predictions as #1, #2, #3, etc. In those cases, rank was assigned based on the precedence of the prediction in the article. I.e. if a specific prediction was listed before another prediction , it was assumed that prediction ranked higher.

Other Insights

The Most Frequently Referenced Categories, Categories by Top 3 Rankings and Overall Rankings of 2017 Predictions Results listed above provide a few instances of correlation with and diversion from the 2017 HCEG’s Top 10 list.

Note: The contents of the tables below were were culled from the various articles listing 2017 Predictions. 

Emerging Technologies

On area of divergence between the HCEG Top 10 list and 2017 Healthcare Predictions Baseline is that Emerging Technologies were not clearly identified by HCEG as of primary focus in 2017. In general, “emerging technologies” are identified as things like 3D printing, AI/machine learning, augmented reality, Blockchain, cloud, drones, Internet of Things, medical devices and robotics. One may argue that, given HCEG’s membership is skewed toward health plans/payers, that  these emerging technologies are not part and parcel of a healthplan/payer-based focus. Given their dominance and potential value, perhaps they should be?

Some Predictions on Emerging Technologies

Adoption of technologies within realm of AI, including RPA and machine learning, will move very fast and take over in many different ways.
Blockchain will move from theory to practice, as pilots and production-ready applications become a reality.
Hype around the Cloud quiets down as it becomes the primary way to build enterprise architecture.
60% of healthcare applications will collect real-time location data and clinical IoT device data and embed cognitive capabilities to discover patterns
Gadgets will continue to be commoditized and competition will grow
IoT will save $1 Trillion a year in maintenance, services & consumables
50% increase in the use of robots to deliver medications, supplies, and food throughout the hospital

Health Reform/Regulations

Given the largely unexpected results of the presidential election, it’s not a surprise that the uncertainty of healthcare reform and regulations jumped to the top position for impacts to healthcare in 2017. Elections have consequences. No doubt as one prognosticator stated “The Trump Presidency Will Rock the Healthcare Boat.”

Some Predictions on Health Reform/Regulations

Massive confusion on status of the ACA
President-elect Donald Trump will likely not fulfill his promise to completely repeal the ACA
The Trump Presidency Will Rock the Healthcare Boat
Regulation drives demand for advanced data and analytics capabilities
Movement by employers away from defined benefit plans to defined contribution plans and increased participation in private exchanges. –
Expand the use of health savings accounts for consumers.
Medicaid expansion costs will be incorporated in the Medicaid block grants
Republicans will attempt to “modernize” Medicare through vouchers or tax credits
There will be continued movement to narrow network products in an attempt to hold down costs.
Federal insurance license changes allowing for competition and selling over state lines
Healthcare startups: Make nice with regulators in 2017

Analytics & Big Data

Predictions about the importance of healthcare analytics made by HCEG members was one area that matched the general baseline as ranking #3.

Some Predictions on Analytics & Big Data

AI (artificial intelligence) or machine learning to translate big data into actionable insights
Convo on healthcare becoming one of most interesting “Big Data” petri dishes society has to offer begins.
Evidence-based decision making (expanded use of data and analytics) to eliminate unnecessary utilization and increase patient safety
Contextualization algorithms will advance exponentially
Advancing data governance
Combining structured and unstructured data
Consortiums of data: genomic, social, EMR, complaint and prescription data, emerge that will create insights never before possible
Mastery of unstructured data will deliver customer insight
Moving to metadata
Taking advantage of real-time data
Startups in analytics space begin to challenge  large, incumbent players and healthcare organizations will begin to actively engage with these new players.

Value-based Reimbursement

Value-based care and reimbursement were highly ranked on both the HCEG Top 10 list and the 2017 Healthcare Predictions Baseline. Given the importance of value-based reimbursement and general bi-partisan support for value-based initiatives like MACRA, VBR should largely survive drastic alteration under the new administration.

Some Predictions on Value-based Reimbursement 

Value-based care will drive adoption of tools for chronic disease management
Easing the training wheels off value-based payment
2017 will be a year for learning about the alternative reimbursement methodologies and planning for the compliance program requirements of the future.
Preparing medical students for work in a value-based world
More performance-based measures beyond cost to quality and satisfaction
Renewed and upgraded Enterprise Resource Planning Systems (ERP) swings back into importance, now for Value Based Care Costing.


HCEG members ranked ‘access’ topics lower than the general baseline.

Some Predictions on Access

The rise of decentralized healthcare and the decline of hospitals.
Significant rise in voluntary services/ healthcare for the wealthy
Self-select virtual care – for convenience
Telehealth will no longer be on the outskirts, pushed into the mainstream with expanded reimbursement policies, usage and outreach programs

Additional Insight Can Be Obtained Here

HCEG Top 10 Info

Collection of 2017 Healthcare Predictions

Raw Data – here is the raw data collected from the various articles on 2017 Healthcare Predictions

Following is a List of Articles used for this analysis – See more info here.

# Title
1 “3 Mega Trends for Healthcare Marketers to Leverage in 2017”
2 “5 healthcare technology trends taking center stage in 2017”
3 “7 Bold Predictions for Healthcare in 2017”
4 “Healthcare CFOs weigh in on 2017 challenges, trends in latest surveys”
5 “Healthcare Industry Trends to Watch”
6 “Healthcare Predictions for 2017”
7 “Healthcare Technology Trends for 2017”
8 “How Consolidation Will Impact Hospitals and Health Systems in 2017”
9 “List Top 10 predictions for IT in 2017 and beyond”
10 “5 healthcare technology predictions for 2017 from Connexica” 
11 “Retail Trumps Healthcare in 2017: Health/Care Forecast for the New Year”  
13 “These Trends Could Reshape Healthcare Tech in the Very Near Future”
14 “Top health industry issues of 2017: A year of uncertainty and opportunity”
16 “Upcoming Trends and Innovations in Healthcare IT 2017”
17 “What to Watch: Health Care Trends for 2017”
18 “10 Predictions for How the Healthcare Industry Will Change in 2017”  
19 “2017 Predictions: Big Data, Digital, and Virtual Care Key to Engage Healthcare’s Empowered Consumer”
21 “4 Business Trends to Watch in the Insurance Industry for 2017”
22 “5 Digital Health Predictions for 2017”
23 “5 Healthcare IT Trends to Watch In 2017” 
24 “7 (plus 1) predictions for healthcare IT in 2017” 
25 “8 Health Tech Challenges and Opportunities in 2017” 
26 “9 Healthcare Tech Trends in “The New Year of Uncertainty” 
27 “Coming Soon to Your Hospital: IoT, Cognitive Computing, Robots and More Ransomware”  
28 “Healthcare Predictions 2017: Accelerated Adoption of Alternative Payment Models”   
30 “How market changes will influence data priorities in healthcare”
31 “Post-Election Predictions for the Healthcare Industry”  
32 “7 digital health predictions for 2017” 
33 “Tom Main and Welltok’s Jeff Margolis Make Their 2017 Predictions” 
35 “2017 Healthcare Trends Forecast: Spok Leaders Weigh In” 
36 “2017 Predictions from Healthcare Leaders Across the Country” 
37 “Trends in health IT for 2017: Ransomware, RPA, blockchain predictions”  
38 “8 technologies that will transform healthcare in 2017 and beyond”  
39 “Five Health IT Trends I’m Looking Forward to in 2017” 
40 “The election is over: 3 health care predictions”  
41 “2017 Predictions: Medicare, Drug Costs, Cybersecurity and More” 


Next Stage of Reimbursements

By | Next Generation Payment Models, Payers

2015.07.28 - ReimbursementyTo those of us who have been in the healthcare industry for more than a few years, the perennial discussion about moving away from fee-for-service is getting a bit tiresome when do we stop talking and start doing on a broad scale.

When we look back at the 1960’s (Medicare and Medicaid were passed in 1965), the story was about getting more dollars into the system to pay for the care of elderly and disadvantaged populations. Today, we’re in a serious hunt to find ways to wring dollars out of the system. And the journey we’ve taken with Medicare tells us a lot about what has happened and will happen in the commercial sector.

When Medicare was implemented we paid providers based on submitted charges what seems like a quaint and na’ve approach, but alternatives didn’t show up until 1972 (the HMO Act), with the first reimbursement reform appearing in 1989 when the first step toward non-charge based reimbursement was legislated for Medicare a requirement that professional providers be paid according to a relative value scale. Medicare HMOs didn’t appear until 1997. Every few years another tweak in benefits or payments was legislated, with 2003 bringing the first prescription drug coverage. 2008 started Medicare, tracked in large part by commercial health plans, down the road to mandated reporting on quality measures, federally-incented investments in EHRs, and penalties + payments to drive better, more cost-effective care.

Finally we capped off the decade with the passage of the Affordable Care Act which included not only reforms to the insurance business but various permanent programs to reduce overall costs and improve outcomes. As we look to 2016, when HHS plans to make 30% of its fee for service payments through alternative models and 85% of payments tied to quality or value, growing in 2018 to 50% and 90% respectively, it’s clear we’re moving into a serious doing phase.

For some expert thinking on what this doing phase looks like already and where it’s headed, please join us for our panel discussion From Concept to Reality: Practical Considerations of Implementing Alternative Reimbursement Models. To understand the doing phase, we need to listen to expert doers, and we will be privileged to hear from three of them.

Dr. DiLoreto will talk about how delivery systems are responding to new reimbursement models and provide his perspective on ways payers can work more effectively with their networks.

2015.07.28 - Reimbursementy PromoDan Tuteur will share his lessons from developing innovative reimbursement methods in a startup health plan forging brand new provider relationships.

Craig Samitt will talk about actualizing the vision of changing physician behavior by aligning incentives based on his personal experience.

After their respective brief presentations the panel will take your questions and engage in a lively discussion. Please do not miss this opportunity to listen to and talk about the real world of alternative reimbursement.