What does it feel like to be a patient, provider, pharmacist, and payer in a world where interoperability is not always a reality? What improvements can be expected by healthcare stakeholders in a world where interoperability is vast?
In our October Webinar Series event – The Care We All Strive For: The Impact of Interoperability – our sponsor Surescripts helped to address the two above questions via a short two-act skit. Four fictional healthcare stakeholders – a patient, a provider, a pharmacist, and a health plan executive – each shared their experiences with how interoperability helps to address the Quadruple Aim: enriching the patient experience, improving outcomes, addressing costs, and maintaining provider well-being.This blog post recaps a portion of this two-act skit and presents some highlights.
Two-Acts: Healthcare System Interoperability – Before & After
In Act I of the skit, each of the actors shared their experience in a world where interoperability is not a widespread reality – a world that most healthcare stakeholders experience today. In Act II, they shared how enhanced interoperability can improve the experience and well-being of not only patients and but also providers while reducing administrative and financial burdens and enhancing clinical outcomes – the four goals of the Quadruple Aim.
Highlights of Act I – Navigating Today’s Processes (Before)
Each stakeholder shared their experience living and working in a healthcare environment where interoperability is lacking:
Patient Carlos Garcia expressed his experience and concerns about alternative medication availability and cost:
Need to repeat medical and medication history with each new provider
Difficulty obtaining info on more cost-effective medication alternatives
Lapses in medication adherence due to cost and/or delays at the pharmacy
Physician Dr. Natalie Pinter, Carlos Garcia’s PCP, noted difficult prior authorization processes and lack of access to benefits information:
Administrative processes take time away from patient interaction
Lack of benefits information makes identifying cheaper therapeutic alternatives more difficult
Cumbersome prior authorization processes – particularly for specialty medications
Pharmacist Keisha Wright also expressed concerns about over-reliance on faxes and administrative burdens:
Challenges with incomplete patient information
Delays in filling prescriptions – particularly specialty medications – due to unwieldy prior authorization processes
VP of Pharmacy at Carlos’s health plan, Oscar Gustafsson, noted impacts his health plan pharmacy operations:
Involve a heavy, over-reliance on faxes to communicate with physicians and pharmacists
Challenges assisting with member medication adherence and addressing gaps
Difficulty assisting members with optimizing the use of their health plan benefits
Navigating Today’s Healthcare Process is a Challenge for Everyone
After Act I, the emcee of the performance – Melissa Warnke, Director PBM-Pharmacy, Health Plan Segment Marketing of Surescripts – shared some recent statistics supporting how insufficient interoperability impacts patients, providers, pharmacists, and health plan payers.
Highlights of Act II – The Care We All Strive For (After)
In the 2nd act, the healthcare stakeholders shared how broad healthcare system interoperability would change stakeholder experience:
Health plan VP of Pharmacy Oscar noted improvements and efficiencies gained in health plan operations:
Allows for timely delivery of medication adherence gaps directly into the workflow of physicians
Ability to share member-specific benefit information to physicians at the point of care
Faster, “faxless” processing and turnaround of prior authorizations
Patient Carlos noted positive impacts on his physician office visit, cost of his medications, and obtaining his medications:
Ability to provide patient medical and medication history to new physicians and pharmacists
Faster, less administratively intense prescriptions – particularly specialty medications – and refills of existing prescriptions
Opportunity to save money with therapeutic alternatives
Physician Dr. Natalie revealed improved ability patient information, reduced administrative work, & more time with her patient:
Patient medical info, medication history, and adherence gaps available electronically in advance of a patient encounter
Electronically accessible benefit plan information facilitates identification and prescription of more cost-effective medication and treatment alternatives
Submitting prior authorizations electronically without faxing
Submitting prescriptions for specialty medications electronically to the pharmacy
Pharmacist Keisha Wright noted reduced patient data collection and streamlined medication processing:
Complete patient and prior authorization info received electronically
More timely processing – especially with specialty medications – allows for more time counseling patients
The Care We All Strive For – The Vast Reality of Improved Healthcare System Interoperability
At the conclusion of Act II, Surescripts Melissa Warnke shared an overview of the vast impact that improved interoperability can have on increasing the transactions that help address the Quadruple Aim. Melissa also shared some additional statistics showing the growing pervasiveness of interoperability. Click images to expand.
A Faxless Future: Dare We Dream?
After Melissa recapped Act II, a short, light-hearted video was played showing how fax machines might be re-purposed for a useful life after they retire from their long-running service to the healthcare industry. The following are a few examples of how fax machines might serve a new role. See the short video“A Faxless Future: Dare We Dream.”
Questions from the Audience on Healthcare System Interoperability
After the video was played, emcee Melissa Warnke fielded some questions submitted by attendees. Here are a few of the questions and their responses:
What have you seen as the best practices for driving the kind of behavior change from providers, pharmacists, and others that obtaining maximum value from increased interoperability takes?
Our Webinar Seriesevents are one example of how the HealthCare Executive Group helps to share information and promote collaboration between healthcare leaders, change-makers, and other stakeholders serving the healthcare industry.
For more information on the topics presented by Surescripts in our October Webinar Series:
Has 2020 given you webinar fatigue? The seemingly endless run of virtual events and webinars would certainly justify it. And while moving everything to the digital world has its challenges, society is embracing technology and making the most of the situation. Healthcare is no exception. With the expanded use of technology, healthcare has been reminded of the importance of being able to communicate with each other quickly, efficiently, and easily.
Please join us on Wednesday, October 28th at 11:00 am PT / 2:00 pm ET to hear the story of what it feels like to be a patient, provider, pharmacist, and payer in a world where interoperability is a reality.
Our sponsor Surescripts will be joined by four healthcare stakeholders who will share their take on the difference interoperability makes on the experience of a patient, provider, pharmacist, and payer. The panelists will examine how sharing information across stakeholders can reduce administrative burden and improve member experience.*:
Dr. Natalie Pinter
Keisha Wright, RPh
Patient with Rheumatoid Arthritis & Hypertension
Pharmacist, Specialty Pharmacy
Vice President of Pharmacy, Payer
Over the next four weeks leading up to the live webinar on October 28th, we’ll be sharing more information on how patients, providers, pharmacists, and payers all benefit from enhanced interoperability of data and systems. In the meantime, learn more about how Surescripts addresses healthcare interoperability challenges here.
* These are imaginary personas whose role in this webinar will be performed by employees of our sponsor Surescripts.
Currently, people with back and joint pain experience a fragmented approach to care. Whether it’s an acute injury, chronic pain, or surgery, members must contend with multiple providers and handoffs between those involved with providing a ‘whole person approach’ to care. From the individuals’ perspective, it feels like no one is looking at their health holistically or acting as their healthcare champion. And with many people increasingly working from home due to the coronavirus pandemic, challenges related to musculoskeletal conditions – increasing back pain and joint pain – are likely to increase.
Our September Webinar Series event was presented by Hinge Health’s CEO Dan Perez and addressed the following:
Key MSK Challenges & Trends in 2020 and Beyond
Fractured State of MSK Care
Towards Next-Generation Care
World’s Largest Digital MSK Cohort Clinical Study
This post is a recap of the webinar. Contact Hinge Healthfor access to the webinar recording
For more information on how a digital musculoskeletal clinic – covering the full continuum of care from prevention to post-surgery – can provide a one-stop-shop for health plans, employer groups, and provider organizations, reach out to Hinge Health.
Highlights from Towards Next-Generation Care: The Digital Musculoskeletal (MSK) Clinic
HCEG’s Executive Director Ferris Taylor kicked off the webinar noting how Hinge Health addresses 4 of the 2020 HCEG Top 10 list of challenges, issues, and opportunities facing healthcare leaders.
Dan shared information, statistics, and Hinge Health insight on the Gold Standard for Addressing Chronic MSK Pain: a biopsychosocial approach that addresses three key components:
How exercise therapy can help reduce chronic pain by up to 60%
How a belief in oneself often leads to lower pain levels – even 1 to 2 years after the initial intervention
How education and 3rd-party support can empower people to overcome chronic pain
Clinical Care Model Surrounding an Individual
The presentation continued with Dan sharing an overview of the clinical care model upon which Hinge Health’s care model is based. He shared a 1-minute video with webinar participants offering a real-world application of the Hinge Health solution.
The World’s Largest Digital MSK Cohort Study
Details on clinical outcomes from a study of 10,264 participants – validated by researchers at Stanford, Vanderbilt, and top consultants addressing key business questions – were shared:
4 out of 5 participants had meaningful improvement in pain reduction
More exercise therapy and coaching resulted in more pain reduction
58% Reduction in depression and anxiety scores
More than 2 out of 3 surgeries avoided in Year-1
The presentation concluded with key takeaways on how health plans, employer groups, provider organizations, and other healthcare stakeholders can help their members and patients.
Learn How Hinge Health Can Help Address Costly MSK Issues
To access the webinar recording and for more information on how a digital musculoskeletal clinic – covering the full continuum of care from prevention to post-surgery – can provide a one-stop-shop for members and health plans reach out to Hinge Health.
Our Webinar Seriesevents are one example of how the HealthCare Executive Group helps to share information and promote collaboration between healthcare leaders, change-makers, and stakeholders. Consider joining our newsletter to stay abreast of challenges, issues, and opportunities of importance.
Employers and health plans interested in truly solving their musculoskeletal (MSK) issues must assemble a collection of disconnected vendors such as prevention/wellness, tele-PT, digital programs, expert medical opinion, centers of excellence (COEs) – resulting in a fragmented member care experience.
To address these failures in the continuum of MSK care, our most recent sponsor, Hinge Health, is pioneering the world’s most patient-centered Digital Clinic for back & joint pain. By expanding their clinical capabilities to provide an end-to-end Digital MSK Clinic, Hinge Health meets members along the MSK continuum of care from prevention to post-surgery.
Hinge Health’s Clinical Care Model Delivers Industry’s Best Engagement & Outcomes
Through its use of virtual physical therapy, behavioral health coaching, and digital sensor technology, Hinge Health’s virtual clinical care model delivers the industry’s best engagement and outcomes. The clinical expertise of our physical therapists paired with the motivational and behavioral training of our health coaches results in the industry’s highest adherence rate with a participant completion rate 3x the industry average.
Hinge Health’s solution addresses several key items on the 2020 HCEG Top 10 including Costs & Transparency (#1), Consumer Experience (#2), Holistic Individual Health (#6), and Accessible Points of Care (#8). As patients avoid doctor and hospital visits during COVID-19, Hinge Health’s at-home digital MSK care provides a more holistic and accessible approach to care resulting in better outcomes at a lower cost.
Musculoskeletal Outcomes Validated by Stanford, UCSF & Vanderbilt
With all the hype around digital health, many employers and health plans might be wondering: Do digital health solutions actually solve chronic back or joint pain and reduce medical spend? MSK issues are the number one cost driver for medical spend—outpacing other conditions such as diabetes and cancer. However, in the world’s largest digital MSK study, researchers from Stanford, University of California San Francisco, and Vanderbilt University, demonstrated that Hinge Health’s digital MSK solution directly results in better outcomes at lower spend.
With over 10,000 participants, the longitudinal cohort study revealed that Hinge Health resulted in:
69% average pain reduction–that’s 4x more pain reduction compared to opioids
58% average reduction in depression & anxiety
3 in 4 participants completed the program, making it the industry’s highest 12- week adherence rate
$5,012 medical claims savings per participant per year
With nearly 200 enterprise customers, Hinge Health partners with employers and health plans to address member MSK pain and reduce high medical costs. With Hinge Health’s fast and easy implementation process, customers can deliver at-home digital care to help resolve members’ chronic back and joint pain.
Customer Testimonials on Value of Musculoskeletal Program
Having nearly quadrupled their customer base in 12 months, Hinge Health is privileged to be the choice of 4 in 5 employers with a digital MSK solution including Boeing, AutoZone, US Foods, Southern Company, Walgreens, PwC, FujiFilm, and more.
Single, Coordinated Program
Additional Information on Hinge Health’s Musculoskeletal Platform
Check out the Hinge Health website, the Hinge Health blog, and the following information on how musculoskeletal solutions can help improve outcomes, lower costs, and improve member engagement.
Over 30 years ago, C-suite leaders of healthcare organizations came together to form the Managed Care Executive Group (MCEG) – a peer-to-peer mentoring concept used to help its members solve their problems with input and advice from other group members. And 60 years before MCEG was born, Napoleon Hill – author of the popular book Think and Grow Rich – shared the idea of Mastermind Group. In 2014, the Managed Care Executive Group rebranded as the HealthCare Executive Group (HCEG) and continued its mission as a Mastermind Group for healthcare executives.
More Than a Conference Organizer, Media Outlet, or Online Networking Group
In its essence, the HealthCare Executive Group is a Mastermind group comprised of senior healthcare executives and industry leaders focused on transforming the healthcare system. HCEG is not purely a conference organizer, a media/content producer, or promoter of online events but rather an organization chartered to convene and support executive leaders of health plans, health systems, and provider organizations – throughout the year – in their mission to affect true change in our failing healthcare system.
The majority of HealthCare Executive Group members are senior executives associated with health plans, health systems, and risk-bearing provider groups. Memberships at the individual and company levels are available each providing various levels of benefits including discounted to complimentary access to our Annual Forum, events, thought-leadership, and personal development opportunities.
Partnering to Enhance Collaboration, Content and Networking Opportunities
HCEG has established both formal and informal partnerships with complementary organizations that also serve our members and other healthcare industry participants associates. These partnerships extend and complement the content, networking opportunities, and value offered by HCEG and its partners. For 2020, these partnerships include:
“The conference is a great conference for the level of executives and people that you have in the room talking about issues. There’s not a lot of primers at this conference which is nice. You’ve got people who are ready to dig deep on issues and can have executive-level conversations pretty quickly. And yesterday, I identified three or four potential partnerships between our organizations and how we can work to solve some of these issues together.” – Ricardo Johnson, Senior Director Healthworx at CareFirst BlueCross BlueShield
“I think they nailed the 2020 Top 10 list (of challenges, issues, and opportunities facing healthcare leadership.) I mean it, really every item on there would have been in the top of my list as well. I think that this group of people has really identified the top issues in the industry and gathered folks who are uniquely qualified to speak to them.” – Sara Stevens, VP of Healthcare Economics & Analytics Ops at Capital District Physicians’ Health Plan
“I think the word is it’s (HCEG’s Annual Forum) still intimate by design. We like to keep it roughly a hundred or so people. The last thing we wanted to be is a giant circus of people who don’t have the chance to share information and have an intimate discussion – so that’s by design.” – Richard Lungen, Managing Member at Leverage Health
A limited number of healthcare industry product and service vendors serve as sponsor partners to underwrite and assist with HCEG’s events, programming, and content. HCEG’s sponsor partners play a role unlike many vendors who sponsor other healthcare events. Rather than dominating speaker positions, exhibiting products in a booth, or littering HCEG’s physical and digital channels with sales messages, HCEG requires its sponsor partners to serve in a supportive, consultative role on a year-round basis.
Sponsor Partners of HCEG contribute to ongoing educational initiatives and benefit from increased visibility through our year-round thought leadership opportunities via:
As America celebrates Thanksgiving, the HealthCare Executive Group (HCEG) is honored to have the support of our sponsor partners and acknowledge the contribution these leading healthcare companies have provided and continue to provide to our healthcare executive members, industry advisors, and associates throughout the year. Through the support of the companies highlighted below, HCEG is able to provide a comprehensive package of information, events, and networking opportunities throughout the year.
The HealthCare Executive Group offers our sincere thanks to these leading vendors of products and services that help improve health outcomes and lower costs.
HealthCare Executive Group – Gold Sponsors
Appian provides a low-code development platform that accelerates the creation of high-impact business applications. Many of the world’s largest organizations use Appian applications to improve customer experience, achieve operational excellence, and simplify global risk management and compliance. For more information, visit www.appian.com.
For 30 years, eQHealth Solutions has been improving healthcare quality and reducing costs through innovative technology, population health management solutions and medical management services. Our expansive offerings include eQSuite®, a cloud-based, SaaS technology coupled with eQCare®, a community-based services portfolio. This combination of technology (high-tech) and community-based services (high-touch) covers all your population health management, care coordination, and utilization management needs.
Softheon delivers cloud-based solutions that create a retail-like, user-friendly experience and provide personalized communication and real-time support to boost member engagement. Cost effective, and configurable software that supports health plans and states with enrollment, member billing, and reporting for over 3.2M Americans.
Care management belongs at the center of healthcare, powering every element in its ecosystem. HELIOS is the first solution capable of seamlessly connecting all data points in the care continuum, and leveraging the workflows and analytics to make a significant impact. HELIOS provides the digital connective tissue between payers, providers, and members.
Built to Transform Interactions between Clinicians, Pharmacists, and Patients
The Surescripts Network Alliance unites virtually all electronic health records (EHR) vendors, pharmacy benefit managers (PBMs), pharmacies and clinicians, plus an increasing number of health plans, long-term and post-acute care organizations, specialty hubs and specialty pharmacy organizations.
Solera connects patients, payers, and physicians to a network of partners who are preventing and managing chronic disease.
Working with Solera, health plans and other payers securely and efficiently leverage a network of community-based and digital health solutions.
Solera helps employers identify and engage those in their workforce with the greatest opportunity for obesity-related chronic disease prevention.
The First and Only Consumer Experience Platform Built Specifically for Health Insurance
Zipari is the only consumer experience technology company to exclusively specialize in health insurance and offer native understanding of the industry, which means we instinctively understand our clients’ goals.
Change Healthcare consulting is a catalyst for your value-based healthcare system. Change Healthcare is a healthcare technology company that offers software, analytics, network solutions, and technology-enabled services to help create a stronger, more collaborative healthcare system. Change Healthcare helps deliver measurable value not only at the point of care, but also before, after, and in between care episodes.
InstaMed powers a better healthcare payments experience on one platform that connects consumers, providers, and payers for every healthcare payment transaction. InstaMed’s patented, private cloud-based technology securely transforms healthcare payments by driving electronic transactions, moving money and healthcare data seamlessly and improving consumer satisfaction.
Health insurers must act quickly to launch new offerings targeted at member populations in specific market segments. Whether a government program, commercial or individual product, or dental or TPA offering, HealthEdge works with transformative health plans to create and maintain a competitive advantage.
The 10th Annual Industry Pulse research survey opens today!
And healthcare industry leaders are encouraged to share their take on the challenges, issues, and opportunities they’re facing in 2020 and beyond. Based on the 2020 HCEG Top 10 list and conducted jointly by the HealthCare Executive Group and Change Healthcare, the survey is intended to flesh out and explore what leaders of healthcare organizations may be facing in the immediate future. Everyone reading this post are encouraged to complete the survey and share it with their co-workers and associates. Just taking this survey will provide respondents with thought-provoking questions and offer ideas they may otherwise not be aware of.
2020 HCEG Top 10 as Basis for 10th Annual Industry Pulse Survey
This 10th annual instance of the Industry Pulse collects additional insight, experiences, and opinions on specific items of the 2020 HCEG Top 10 list developed in September 2019 at HCEG’s 31st Annual Forum. The questions, possible responses, and results of the Industry Pulse can provide valuable, relevant data-driven advice and end-to-end industry insights to help healthcare leaders navigate the complexities of our rapidly evolving healthcare system.
Share your Insight Today!
HCEG and Change Healthcare would like to invite healthcare leaders from across the nation to participate in this year’s Industry Pulse research survey and to compare and contrast their own perspectives against the 2020 HCEG Top 10.Please consider sharing your insight, experiences, and opinion as your perspective will help define the issues facing healthcare, and reveal how the industry is responding. Everyone who completes the 10th Annual Industry Pulse Survey will be among the first to receive survey results as well as exclusive access to future webinars, content, and events that will be delivered over the new year; expounding on survey results and providing additional insight and value to all healthcare constituents.
People, process, and technology are at the core of every business. And how these three critical components are used to create and deliver a healthcare organization’s products and services ultimately result in company profitability and growth. Indeed, the critical challenges healthcare organizations are facing during these uncertain times involve humans, the processes they must follow, and the mix of entrenched, emerging – and as yet- often unknown technologies supporting an organizations mission and growth.
The Golden Triangle: People, Process, & Technology
Delivering operational efficiency, a key aspect of transforming today’s healthcare organizations requires an approach that optimizes the relationships between people, process & technology; hence the Golden Triangle. Each part of the Golden Triangle is its own science. And each needs to be mastered to effect true transformation and business growth. Ignore the relationship between people, process, and technology at your own risk.
And know that the art, where real value and efficiency are found, is at the intersection of people, process & technology. Like a three-legged stool, each part of the Golden Triangle must be sufficiently developed and aligned as integral components of successful transformation initiatives. Too often, healthcare organizations give short shrift to the people point of the triangle.
Successful Transformation Initiatives: Keys to Success & Challenges
In a study by IBM titled “Making change work…while the work keeps changing,” 1400 participants identified the keys to successful change initiatives and the major challenges to change that organizations must consider as they plan and strategize their business transformation initiatives.
Keys to Successful Change Initiatives at Healthcare Organizations
Honest and Timely Communication
Change Agents to Engage Other Employees
Change Supported by Culture
Efficient Training Programs
Monetary and Non-Monetary Incentives
Adjustment of Performance Measures
An Efficient Organizational Structure
Top Management Sponsorship
Challenges to Change Initiatives at Healthcare Organizations
Changing Mindsets and Attitudes
Shortage of Resources
Lack of Commitment by higher management
Insufficient Change Know-How
Little to no Transparency
Impact on Existing Process
Flexibility and Interoperability of Technology Systems
See this article for more about the keys to successful change initiatives and the major challenges to change that organizations must consider as they transform their organization.
People are Key to Aligning People, Process, & Technology
Famed IBM founder Thomas J Watson shared the following on the importance of NOT ignoring the people component of organizational change initiatives.
“Teach your associates to teach themselves and in a way that you will strengthen the entire organization” – Thomas J Watson (1947)
Additional Insight & Ideas on Leveraging People, Process, & Technology
In today’s uncertain and rapidly changing healthcare environment, healthcare leaders are seeking to enter new geographies, start new lines of business, or even radically transform their traditional way of doing business. To position your healthcare organization for successful growth by optimizing the intersection of people, process, and technology, join us on July 25th for our Webinar Series event: Using People, Process & Technology to Grow Your Business.
Sal Gentile, CEO of Friday Health Plans and our sponsor partner HealthEdge will share how they leveraged the art and science of people, process and technology to successfully grow their respective healthcare organizations both from the ground up as well as within an established organization.
If you’re not sure whether you can attend this HCEG Webinar Series event, go ahead and register and we’ll send you the recording/recap.
If you have any questions about this blog post or want to learn more about the HealthCare Executive Group, please reach out to us at [email protected]. Also, consider following @HCExecGroup on Twitter and LinkedIn.
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.
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.]
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.”
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.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.
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:
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:
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.
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?’
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?
Is our plan performing better than what it was before from a cost standpoint?
Are we improving the quality of our plan?
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]
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.
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
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.
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.
Intuitive Easy-To-Use Platform
Actionable Real-Time Data Visualization
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.
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.
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
If analytics is the machine powering your digital transformation initiatives, then data is the power making that digital transformation machine run. The importance of data and analytics has been identified by our members in each of the last ten years HCEG’s Top 10 list of challenges, issues, and opportunities have been created. For 2019, “Data & Analytics” is ranked #1 on the HCEG Top 10. It’s clear that healthcare leaders believe that data is a catalyst to accelerate meaningful change. And that the use of analytics – particularly prescriptive analytics – is a fundamental strategy for succeeding in a new era of healthcare.
Mountains of Data Waiting to Power Your Healthcare Analytics Machine
Good analytics begins with good data and healthcare organizations are sitting on a mountain of data. According to America’s Health Insurance Plans (AHIP), the typical regional payer processes $8 billion in claims each year with each claim providing its own set of unique data points – largely financial and administrative. But healthcare payers are increasingly collecting, matching, and using clinical data to provide richer, more comprehensive insight on their members.
Given the proliferation of Electronic Health Records (EHR) incented by CMS’s Meaningful Use program, it’s no surprise that more and more data is being pulled from EHR’s. And risk-sharing agreements between payers and providers has resulted in health plans sharing more claims data with their provider partners. In fact, the current Industry Pulse report indicates that EHR data is one of the top two primary sources of clinical data with 30% of health plans reporting they utilize EHR data.
Other sources of clinical data that organizations are using to complement their claims data include ancillary data such as pharmacy, lab, and imaging (17%) and real-time admission, discharge, and transfer notifications (10%)
These enhanced data sources are becoming more and more useful due to the power of artificial intelligence (AI) and machine learning.
New research from Dimensional Insight identifies care quality measures and finance as two top use cases for healthcare organization usage of analytics today. Additional use cases for leveraging data by analytics include
Addressing Social Determinants of Health (#3 on the 2019 HCEG Top 10)
Value-based Care and Alternative Payment Models (#4 on the 2019 HCEG Top 10)
Improving Patient Engagement and Satisfaction
Patient Outcomes Improvement
Analytics Budgets are Increasing for Healthcare Organizations
Additionally, the report finds that 89% of healthcare executives plan to use predictive analytics over the next five years. It’s clear that healthcare payers and health systems have a keen focus on leveraging the massive amounts of data they possess. These data serve to reveal trends, patterns, and insights to help ensure their success going forward.
Solving the Rubik’s Cube of Payer Data
i.e. Lining Up All Your Data to Rapidly and Accurately Gain Unique Insights
For insight into how your healthcare organization’s data can be used to improve health outcomes and reduce costs, join our next Webinar Series Event on June 6th at 2:00 PM EDT / 11:00 AM PDT. Our sponsor partner eQHealth Solutions presents “Solving the Rubik’s Cube of Payer Data.”In this complimentary webinar, you will learn how to aggregate and parse provider data, how you can use data captured outside of your own system, and other practical solutions to use your data to create knowledge for actionable use and outcomes. Attendees will have a chance to ask questions and all registrants will receive a copy of the presentation afterward.