Ready or not, here comes reform
While health reform has been in motion for more than two years, the Supreme Court’s recent go-ahead on the Affordable Care Act solidified that change is on the way – change that will impact stakeholders across the entire healthcare ecosystem.
The influx of new patients under the individual mandate and concurrent creation of health insurance exchanges, coupled with a drive towards efficiency and quality-based pay, present a myriad of challenges that will affect bottom lines for payers and providers of all shapes and sizes. Whether the impact is positive or negative will be determined by how well organizations plan for these changes.
While the individual mandate has the potential to be a boon for insurance plans, the new system of exchanges puts these groups under unprecedented pressure to compete for business and strategically align patients with plans. At the same time, providers are staring down a wave of new patients while their reimbursement structures undergo a historic shift towards more stringent, quality-based measures. As this transformation unfolds, healthcare organizations must better understand both their current and prospective communities of patients – and they can’t do it without meaningful data.
Right now, most health stakeholders have at least a basic data infrastructure to build from, but few existing resources are “future proof” despite the future being right around the corner. While this era of change presents significant challenges on the data front, it’s also ripe with opportunity for those who choose to take advantage.
On the payer and managed care side of the industry, historic claims data provides organizations with a wealth of knowledge about their members’ use of services while covered under their particular plan. Once the reform law’s healthcare exchanges are up and running at full steam, their members will have unprecedented tools at their disposal to shop for new products or entirely new carriers. Some will switch from product to product under the same carriers, while others will change carriers altogether. In those scenarios, historical claims information will be lost, and new carriers will be left with a blank slate likely be filled in with self-reported history.
Risks presented by these data deficiencies are significant, but also manageable through solutions that provide a true competitive advantage. For example, as plans and managed care organizations prepare for the influx of potential enrollees, demographic data will enable them to identify the characteristics of their service areas and prepare accordingly, allowing them to tailor plans to the specific needs of individual communities.
When combined with existing historical claims information, this data can help managed care organizations (MCO) shape their member outreach to proactively manage care and highlight the particular strengths of their network’s services. Developing predictive models that combine historical claims data with demographic characteristics will allow MCOs to create targeted outreach programs for high risk patient populations within their network.
Providers face a very similar set of challenges and opportunities, as they’re likely to have only historical medical record information for the services provided in their own offices or within a group of connected providers. In a somewhat disadvantaged position, providers will have to work collaboratively with their MCO counterparts to gain longitudinal insight into the care patients are receiving outside of their practice. They will need access to as much information as possible to make the kinds of efficiency and coordination improvements required as reform becomes a reality.
Supplementing limited sets of existing data on patients will be an imperative for both risk management purposes and business growth. Historically, providers have been able to determine referral and admitting patterns based on their own data sets. For example, if a particular zip code lacks an urgent care setting and those patients are using a system’s emergency room, the organization would consider staffing an urgent care clinic in that area to help reduce costs of care.
In the future, further insights can be gained by understanding the demographics of that population and their likelihood to have chronic conditions. Further care coordination efforts may be prudent to improve quality and further reduce costs through proactive care management and education.
As the entire health ecosystem faces record change, institutions must devote unprecedented resources to both managing risk and identifying opportunities to operate more efficiently. The intelligent use of data will be indispensable in this new health era.
Jim Bohnsack is vice president of TransUnion Healthcare.
