The coronavirus pandemic is proving to be a seminal moment for health payers eager to reimagine their role in ensuring that members have access to timely and appropriate care. Doing so requires health plans to eliminate a significant barrier in the way of effective patient care — the fragmentation of data, solutions, and stakeholders.
“If organizations have legacy technology solutions, they likely have silos with their data,” says Vital Data Technology President & CEO Matt D’Ambrosia.
COVID-19 made clear the existence of intra-organization silos that have a direct negative impact on member experience as well as the need for health plans to bring together solutions, stakeholders, departments, and data in a way that recognizes them as trusted advocates for their members. Responding with a sense of urgency is necessary for payers to remain competitive in a post-pandemic world.
“Health plans can no longer limit their work to claims processing and administrative functions,” D’Ambrosia explains. “Coming out of this pandemic, this is the opportunity for health plans to truly emerge as innovators, enablers of being able to leverage data, data science, and the opportunity to engage all the appropriate stakeholders. When you think about it, health plans were the original accountable care organizations, accountable for the quality, cost, and for driving innovation.”
Health plans are in an advantageous position to reconcile the numerous disconnects plaguing the healthcare system by employing a unified data structure that allows a panoply of solutions — both inputs and outputs of those solutions — to be transparent, actionable, and leveraged across the enterprise. To achieve this end, they must think differently about data aggregation and the extensibility of intelligence across departments and beyond their own four walls to providers, members, and third-party vendors.
“They have a 360-degree view of member health. No matter the hospital or doctor, member visits and claims are running through that plan. There’s an opportunity for all stakeholders to influence change – to use all of that data to identify opportunities, communicate to members, and engage them in preventative care,” D’Ambrosia emphasizes.
Simply put, health plans need a common platform that goes beyond warehousing data to enable all parties to work with real-time, actionable information. Data must become intelligent and prescriptive.
“Plans are evaluated and compared to other plans based on their effectiveness of care through programs like STARS and HEDIS. But these initiatives are siloed and can’t be leveraged with other enterprise initiatives. Many plans look at HEDIS measures on a monthly or quarterly basis, and plenty of time passes before they can operationalize that information and engage members,” D’Ambrosia maintains. “But if health plans use a uniform data system with real-time processing and embeds calculations inside of the platform, all of a sudden all departments can have more meaningful engagement with the member.”
By thinking differently about data aggregation and sharing across the enterprise, health plans can achieve new levels of member engagement.
“If you can start communicating to members prescriptively and in a way that is relevant for them, based on real-time information rather than what happened last month, quarter or year, health plans can ensure all stakeholders are on the same page,” D’Ambrosia advises. “That is where the unique opportunity is for health plans to demonstrate to members that they are trusted advocates – members want and need that type of relationship.”
While telehealth continues to garner significant attention, and rightfully so considering current constraints on care access, its success and that of other platforms depend on a strong data foundation.
“When we talk about the pandemic being the driver for that innovation, everyone talks about telehealth, but that’s just a piece of the bigger picture,” D’Ambrosia argues. “It’s the fact that there is all of this data as well as advances in data science and predictive models – and we can leverage these things to effect a positive outcome for the member.”
The process begins by looking internally for signs of interdepartmental fragmentation and removing them.
“Quality management is typically a department that is siloed,” D’Ambrosia warns. “On the Medicare Advantage side, risk adjustment is typically separated from the rest of the house. Care management, case management, population health — in most cases, there are disconnects.”
While bringing these disparate units and information together requires a major technical lift, the payoff for predictive analytics is too significant to overlook.
“We’ve got all the conventional data with labs, Rx, claims, and more, but there’s all of this data that’s generated by the solutions in real-time that need to be taken into consideration. How a health plan can connect everything is the key here. The technical capability to combine all of that data is what healthcare needs to solve for, and how we’re making all of that data available to stakeholders – conventional, unconventional, and operational.”
After a tumultuous year of disruption, healthcare consumers are looking for health plans that are able to meet their changing needs. For payers to meet and exceed these expectations, they need to work quickly to put in place a unified data structure that allows for building solutions and creating real-time intelligence that makes an impact at the point of care.
The pandemic may have accelerated digital transformation by decades, but much more work is left to be done to ensures future success.