Last week, I discussed four competencies that would be required to create a health plan from scratch: 1) operating at peak administrative efficiency, 2) engaging consumers, 3) shifting risk in productive ways and 4) creating the clinical outcomes-driven business. Although traditional IT strategies have often focused on automating existing processes, the new health plan will need to focus on supporting these new competencies with technology.
So, this week, I describe the four key technology enablers underlying the new health plan: 1) cloud computing, 2) sophisticated consumer health portals, 3) tools to support innovative reimbursement models and 4) intelligent, actionable decision support.
Cloud Computing
The new health plan will not have to sustain a large IT shop that supports high-maintenance legacy systems developed over 30 years ago for simpler times. Instead, powerful yet flexible cloud computing connects systems for disparate uses, and the systems share a common database to deliver a cohesive patient story in real time across the care continuum. Freed from a complex integration of legacy systems, the plan can play a key role in connecting and sharing clinical and financial information among providers, accountable care organizations, mini-clinics in retail outlets, insurance exchanges, pharmacies, labs, imaging centers, consumers and any other healthcare entity that may arise in response to healthcare reform or additional industry changes. Interconnected systems sharing a common database also help the plan respond quickly to changing business needs, market imperatives and government mandates.
Sophisticated Consumer Health Portals
To truly engage consumers in financial and clinical decisions regarding their health, the new health plan will provide them with robust Web portals connected to the cloud-based databases. These portals give members everything they need to manage their health and, in so doing, build a new consumer competency around health management. The portals include health risk assessments, offer more granular benefit information and provide lab test results tracking with alerts when personalized actions need to be taken. Members can chat with a nurse 24x7, use integrated social media to leverage the knowledge and support of health communities, and have immediate access to satisfaction scores for doctors and hospitals. The plan shares significant clinical and financial data as well as decision support tools and information with members in an open manner, driving behavior change while building competitive differentiation.
Tools to Support Innovative Reimbursement Models
The new health plan will support the shift to value-based reimbursement models, no matter what shape those models take, minimizing complexity while maximizing outcomes through the right technology. For example, if the plan has worked with its providers to implement a bundled payment program for certain episodes of care, technology automates episode initiation and registration, identification, bundling and reimbursement of included claims. This is coupled with clinical care management to drive improvement in care and analytics to drive the right associated intervention. Analytics are also in place to monitor clinical and financial performance metrics, providing real-time course correction when activities deviate from best practices when an episode is under way as well as continuous feedback for improving the model itself. With bundled payments in effect for a wide range of care episodes, the plan and its providers have successfully transitioned from a volume-based system to one that is grounded in care and financial best practices and value.
Intelligent, Actionable Decision Support
The new health plan will be a true collaborator with its physician networks, using intelligent decision support tools to facilitate what it does best -- manage financial outcomes -- while giving providers the tools they need to support what they do best -- manage clinical outcomes. For example, the plan gives physicians access to an intelligent, evidence-based decision support platform that brings medical and policy information directly to the point of care. This enables doctors to understand whether genetic tests, imaging diagnostics or other procedures are appropriate and covered, what they will cost, where they should be delivered, and what impact they can be expected to have. This approach, in conjunction with cloud-based data storage and value-based reimbursement, enables the plan to effectively measure provider performance and intervene by exception, rather than burden each care event. The plan also uses innovative analytics to move beyond data insights to supporting outreach campaigns that alert physicians and members about opportunities to improve care -- for example, by improving medication compliance in diabetics. As payers and providers each focus on their area of expertise, they naturally support the other to build trust and drive positive outcomes across the healthcare system.
The Future Is Now
With so many processes to re-engineer and burdensome legacy IT systems in place, the idea of starting a health plan from scratch has tremendous appeal. However, it isn't necessary to accomplish meaningful change in today's health plan. Determine which of the four functional competencies I discussed in part 1 are most vital to your organization. Take a step-by-step approach to building those competencies, putting in place the related technology enablers. The beauty of emerging technologies is that in many cases they complement and enhance your existing infrastructure, supplying the business agility that was impossible to achieve in the past.