PHILADELPHIA - Improving the availability, accuracy and delivery of information in an actionable way is at the heart of the myriad reforms impacting the healthcare industry today, according to an IDC Health Insights analyst.
Robust analytics therefore is poised to help payers meet the objective of the healthcare reform initiative, consumer-focused healthcare, the emergence of value-based healthcare and product design, and federal government mandates for electronic health records (EHR), ICD-10 and health information exchange (HIE) adoption, said IDC Health Insights program director Janice W. Young.
Payers are currently looking at analytics solutions for population and care management, retail consumer marketing applications to the individual market, support of new network and contracting methodologies, and clinical outcomes management, she said.
Joe Miller, director of eBusiness for Philadelphia-based AmeriHealth Mercy, a large provider of Medicaid managed care plans in the U.S., acknowledged payer concern for the required investment for these initiatives. Payers need to look at all the pieces of the reforming market from a strategic view and leverage the seemingly competing initiatives - such as ICD-10 conversion and meeting criteria for the meaningful use of electronic health records (EHRs) - in a synergistic way, he pointed out.
For example, ICD-10 aims to provide better clinical documentation for payers, providers and the government, which is also a meaningful use criterion for EHR adoption. Improved analytics can deliver more granular data, which can, among other things, improve targeting for disease management programs, he said. "Using analytics allows us to take far better action to support our members," Miller said.
As patient-centered medical homes (PCMHs) expand from limited pilots to larger rollouts, payers are mindful of program costs and return on investment (ROI). With analytics, payers can identify not only the right population of patients for enrollment but the right primary care physicians to participate in their PCMH programs, said Sanjit Das, senior solution architect, Healthcare Practice, for global IT service provider Infosys Technologies. These streamlined processes help keep costs in check, as well as determine ROI, he said.
AmeriHealth Mercy is using HIEs and EHRs as vehicles to consistently deliver key information gleaned through analytics to providers to improve access, efficiency and quality of healthcare. Payer involvement in HIE is starting to change for the better, with payers supporting and even contributing to the flow of information, Miller said. HIE participation can deliver benefit for payers' members from an outcomes standpoint, he said.
"The final mile in analytics used to be getting information to the right place at the right time.
That final mile has moved," Young said. Once payers have the information from multiple systems and integrate it into best practices, which are delivered through the preferred channel, they can follow up and understand the outcomes."
Increased granularity around ICD-10 will help AmeriHealth Mercy measure clinical outcomes more effectively. "This is a key part of what we're all about - what's the best way for us to achieve those outcomes as a health plan in partnership with our provider networks," Miller said.
Another extension of increased granularity around ICD-10 is the ability to measure the efficiency and effectiveness of individual providers, as well as the provider network as a whole, said Rajiv Sabharwal, chief solutions architect, Healthcare & Life Sciences, Infosys Technologies. Having this level of data and quality measures brings integrity to the credentialing and contract negotiation processes.
In addition to the ICD-10 mandate, new regulations under the Patient Protection Affordable Care Act (PPACA) require payers to spend 80 to 85 percent of consumers' premiums on direct care for patients and efforts to improve care quality, as opposed to administrative costs, beginning in 2011. Analytics can help identify cost overhead and enable payers to correctly credit spending for direct care and administration, said Das. Analytics will also identify the adequacy of their provider networks and determine which networks need to be optimized, which will help reduce operational costs.
PPACA also mandates that individuals purchase insurance, which will further expand the individual market. Payer retention programs can deploy analytics to identify those within their member population who will switch from group coverage to the individual market, as well as identify their current benefits needs, Das said. Measuring the lifetime value of members helps payers identify whom to retain more efficiently.
"As a plan, you want to have a strategic view of all these new and diverse sources of information," Miller said. "From a strategic standpoint, the focus should be on ensuring that the information is integrated in a data warehouse and analytics solution in a way that can be stored efficiently and tapped by many sources without creating islands of information throughout your organization."
"All of these pieces do, in fact, tie together," Miller said. "Through that way, you're in a better position to utilize the information than if you had disparate, piecemeal efforts."
"Nobody knows what all of this is going to look like from a business standpoint over the next two to five years. The role of a robust analytics engine is to clearly enable a plan to understand the reality of changes and not just the theory," Miller said. The intended goal of PPACA, PCMHs and accountable care organizations is to improve outcomes and effectiveness, lower costs and improve access. Payers need to deploy analytics to measure and monitor the changes as they unfold to determine the impact on their organizations, he said.
In her December 2010 Perspective: ICD-10 Return on Investment - Reusability in Health Reform Initiatives, Young highlights the opportunity for technology reuse. "The success of all of the major health reform initiatives will depend on healthcare payers' ability to accurately, consistently, and efficiently codify, track, transact, model and report information," she said.
"The more detailed ICD-10 coding scheme will play an important role in healthcare payers' ability to embrace and support main features of the reform legislation, including the expansion of coverage and benefits, corporate cost containment initiatives, provider delivery, and payment reform," Young said. "As healthcare payers seek compliance consultants and solutions, they should seek solutions that provide ICD-10 compliance and also meet the payment, business intelligence, and business modeling requirements of the healthcare reform era."
This article has been sponsored by Infosys Technologies Limited. Visit www.infosys.com to learn more.
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