How technology can optimze the way payers and providers serve their shared populations.
How technology can optimize the way payers and providers serve their shared populations.
BRIDGING THE DIVIDE
The top priority for payers and providers is achieving the Triple Aim – improving health outcomes, lowering cost, and increasing patient satisfaction. However, there is a distinct di erence in how they set out to accomplish those goals. At a fundamental level, providers and payers agree on the value population health practices o er for their shared customers. It entails strategies designed to positively impact the health outcomes of a group of people. And indeed, there's consensus that by proactively managing at-risk populations, we'll be able to improve health outcomes, reduce costs, and improve patient satisfaction. While providers and payers don't always agree on the most e ective routes to population health, it's essential to come together—to bridge the divide. Within the space between providers and payers are people who need more e ective and a ordable healthcare. Left uncoordinated, population health activities yield suboptimal results across the Triple Aim objectives, thanks to current business models, coordination and care processes, and gaps in information.
So, where do we go from here? To gain insight, we connected with leaders in the healthcare industry. We discovered that there are sizable opportunities in price transparency, telehealth, remote monitoring, and shared data—and in many cases, technology holds the key to success. In the following pages, you'll read expert opinions and promising strategies for providers and payers working to help people get the right care, at the right time, in the right setting.
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Straddling the Priorities in Population Health
MADDY BJORKLUND Healthcare Strategy Lead at Concord
Payers and providers di er in the motivated objectives when they seek to pursue population health agreements for their shared populations. Providers tend to be motivated by driving volume to high-margin services while creating systems, solutions and programs that help manage their entire population well. Their minds go toward the clinical and/or the social attributes of a population and unique services to help them lead healthy lives. These programs are constructed based on the characteristics of their populations, with their mission to keep the patient healthy and stable.
Payers tend to focus on the health of a population with a financial motive - containing unnecessary costs through proactivity and prevention. They work tirelessly to connect with their members directly in support of this philosophy. They also extend their reach through provider incentives that reward for screenings, managing tasks directed at chronic diseases and proactively keeping patients out of the emergency room. Population health is a challenge, but if payers and providers spend the time in good faith harmonizing their objectives, it would expedite the rewards for both of them and the patient.
Payers and the providers have always had a di erent perspective when you say 'population health' to them. But most folks find themselves straddling both sides of the world an awful lot because it isn't a clean-cut situation.”
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Maddy Bjorklund is a seasoned healthcare consultant with extensive experience on both the payer and provider sides of the healthcare equation. Concord is a business consultancy solving problems with strategy, design, and technology.
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The Promise of Price Transparency
Hope is on the horizon Payers and providers working together is the only way to improve price transparency to enable patients to choose high-value options. While a collaborative arrangement doesn’t exist quite yet, we are trending in the right direction. Personalized health plans and digital technology provides new opportunities to improve price transparency and illustrate a stronger correlation between cost and value.
In theory, price transparency offers clear benefits to both the patient and the healthcare system. Wouldn't people make more informed decisions if they understood the cost of care and the price variations between providers and care settings?
Unfortunately, price transparency in healthcare is complicated, misunderstood, and has a long way to go. Here are a couple reasons why:
Varying levels of insurance coverage. Insured individuals rarely pay the total price for their care. Instead, they pay a copay or a smaller amount dictated by their coinsurance or deductible. Consequently, the cost of care will di er from person to person. Payers have made recent strides to enable price transparency—but, in general, it’s still too di icult for someone to know their exact cost of care in advance. Further, understanding the insurance reimbursement and out of pocket cost calculations is convoluted and time-consuming.
Extreme price variation and misperceptions about value.
At a fundamental level, people are largely unaware that prices can vary so much in healthcare for the same service—and why that’s the case. Unlike other consumer goods, high prices in healthcare often don’t indicate better quality. A high price for a surgery, for example, may indicate poor provider outcomes/e iciency or that the care setting isn’t optimal. When people are cognizant of costs before their appointment and understand the reasons for price variations, they will likely choose higher-value care.
The percentage of patients that say a clear estimate of financial responsibility a ects if they'll see a certain provider. 1
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Working Together to Accelerate the Value Illuminated by Price Transparency
MARCUS THYGESON, MD, MPH Chief Health Officer at Bind Benefits | Twitter: @mthygeson
Price transparency is an extremely important strategy for improving the quality and a ordability of care. Better care will result in better health at both the individual and population levels. Payers and providers can and should work together to accelerate the value created by price transparency. One key collaboration opportunity is information sharing. Payers have a lot of information about the costs of care and health outcomes that providers can use to improve their performance absolutely and relative to peers. Providers should systematically collect
information about the quality of care and health outcomes and share that information with payers, so payers can further align benefits with value. This collaboration creates a virtuous cycle – as provider performance improves, the price to the member for that provider's care decreases, more members seek care from that provider, costs go down, and care gets better. Innovative payers and providers are already working together to create this shared vision—a healthcare system focused on value, where provider financial success is tightly linked to health value and e iciency of the care they provide.
Collaboration creates a virtuous cycle—as provider performance improves, the price to the member for that provider's care decreases, more members seek care from that provider, costs go down, and care gets better."
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Marcus has served both sides of health care—as a treating medical doctor and health plan executive. Bind Benefits o ers personalized health plans that provide choice, flexibility, and cost transparency.
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The future of telehealth Patients and providers are concerned about the future of telehealth as we emerge from the pandemic. Will patients still be able to choose virtual appointments for routine care? And, will provider payment be commensurate with in-person appointments? Continuing and expanding access to telehealth seems like a win-win-win for patients, providers, and payers. If more patients stay on top of their health and address minor problems before they turn major, they'll have a better quality of life. Plus, reducing the number of emergency situations would significantly reduce costs to the healthcare system. Ensuring that providers are eager to meet patients wherever they are—in-person or virtually—behooves payers to provide fair reimbursement for telehealth visits. Still, telehealth is not a magical panacea that solves all the access problems. While smartphones are incredibly pervasive—85% of U.S. adults own one in 2022—they are not universal. Further, those with low digital literacy rates are ill equipped to understand how to use these care options. Plus, there will always be times when individuals need an in-person appointment.
Telehealth as a Means to A ordable and Accessible Care
In healthcare, there is increasing pressure to see more patients and keep costs low. The pandemic experience underscores teleheath’s pivotal role in a ordable and accessible healthcare, from video and telephone visits to e-visits. It turns out that patients like the option of telehealth. While many healthcare consumers wouldn't have sought out virtual appointments before the pandemic, most hope telehealth is part of the new normal. For some people, telehealth is a matter of convenience, but for others, it's a need.
For some populations, getting into the clinic is an obstacle. The drive is too far. They can't get time o from work. They can’t find childcare. They don't have transportation. For these individuals, telehealth can mean the di erence between seeking and skipping care, between being treated in a low-cost setting or waiting until it's bad enough to go to the emergency room.
6
8 0
88
would like telehealth to continue after COVID-19
say telehealth can provide quality care
Source: “How Americans Feel about Telehealth: One Year Later." SYKES, https://www.sykes.com/resources/reports/how-americans-feel-about-telehealth-now
Elevating Patient Value Through Digital Assets
various technological solutions to be worthy of implementing and reducing the future costs of visits, for example, by preventing disease complications and avoiding surgical intervention. We have new legislation and Current Procedural Terminology (CPT) codes in the U.S. for remote monitoring and telehealth visits. Employers in the U.S. are spending their own budgets to include such services as a benefit because they believe in the prevention of complications. We see many safety-net hospitals piloting digital solutions for their population for free. The key area in which payers and providers are working together is the empirical evidence of these technologies. New evidence is emerging that sometimes cannot be directly compared to drug e icacy or hospital statistics. But providers and payers are doing a great job assessing this evidence and keeping the requirements high. At the same time, they are adapting to the new world and shaping the industry's entry barriers, so the digital solutions show significant value to the patients.
KASPARAS ALEKNAVICIUS, MD Head of Medical Affairs at Kilo Health | Twitter: @kilohealthhq
Synchronous communication refers to the situations where a care professional and the patient must be present at the same time. Telehealth, specifically through video visits, o ers this accessibility solution for people living in rural areas—they can talk to their doctor from their home, and nobody has to travel anywhere. We see di erent stakeholders incorporating digital solutions into their o erings. There are a few examples of Pharmacy Benefit Managers (PBMs), including mobile apps into their digital formularies, making them available for reimbursement. Insurance companies assess
The key area in which payers and providers are seen working together is the scientific evidence and proof of [telehealth and remote monitoring] ... they are adapting to the new world and shaping the industry's entry barriers.”
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Kasparas Aleknavicius is a medical doctor working as a Head of Medical A airs at Kilo Health. Kasparas is responsible for clinical product development, research, and partnerships. Kilo Health develops digital lifestyle interventions that lead to a healthier life by preventing, managing, or treating various health conditions.
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Data and Technology as Catalysts for Change Data and technology are incredibly powerful catalysts in population health strategies and initiatives. Telehealth, remote monitoring, and price transparency all have data and technology at their core.
BILLION $ 158 Internet of Medical Things (IoMT)
These innovations are only a start. Other developments that are here or on the horizon include:
Expected market size in 2022
Artificial intelligence to identify global health crisis Machine learning to diagnose patients Natural language processing software for charting and claims submission Remote robotic surgery Nanotechnology
All these developments hold promise, and some have the potential to change the face of healthcare forever. Ensuring the best outcomes from these and future technologies will require provider and payer alignment and support.
Source: Medtech and the Internet of Medical Things: How Connected Medical Devices Are Transforming Healthcare. Deloitte Centre for Health Solutions, July 2018.
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Harnessing the Power of Remote Patient Monitoring and Testing
Patient compliance and engagement have long been obstacles in improving population health outcomes. However, a new generation of remote care options is changing that. Wireless trackers such as blood pressure monitors, weight scales, blood glucose meters, pulse oximeters, and spirometers are being embraced by patients to track personal health information and progress towards goals. In fact, over the past couple of years, the number of individuals using remote patient monitoring as part of a treatment program has grown by about 50%. When asked about using these tools, patients say they appreciate the detailed health information and quicker access to healthcare. Physicians note that these remote tracking empowers people to take control of their health, resulting in better outcomes and compliance.
At-home options are especially valuable for at-risk populations who require ongoing testing and follow-up. For individuals with weakened immune systems, remote monitoring can reduce the chance of exposure to viruses and bacteria that may occur with a clinic visit. These tools can also help overcome delays in care and testing, as was common in the early days of the pandemic. "The first step is looking at why people are choosing to defer care," says Yonatan Adiri, founder and CEO of Healthy.io. "Forty-five percent of Medicare beneficiaries who deferred care did so because they didn't want to be in a medical facility, and thirty-five percent didn't want to leave their homes. Therein lies the solution—enabling people to test from home.”
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Remote Monitoring Is On The Rise
The future of remote patient monitoring and testing
Patients Using Wireless Devices that Collect and Share Health Data With Their Providers*
There are astounding innovations in remote care which o er the potential to optimize outcomes while reducing the healthcare burden of costly conditions such as diabetes, heart disease, and asthma. At this point, the onus is on payers and providers to make space for these valuable tools in the care continuum.
45.1M
50M
39.3M
40M
29.1M
30M
20M
10M
2020
2021
2022
*Includes wearable devices, home health devices, and sensors.
Source: “US Remote Patient Monitoring Users, 2020-2025 (Millions and % Change).” Insider Intelligence, Insider Intelligence, 31 Aug. 2021.
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Using Remote Care to Make Every Healthcare Moment Count
Additionally, the spotting of a trend or other worrisome issue can trigger an interaction, whether it be a video visit, asynchronous communication, or scheduling an in-person visit. The key aspect of all of those potential interactions, though, is trying to address an issue before it becomes more serious. This approach demonstrates a shift in perspective from being reactionary to proactive. A proactive approach can maintain better overall health and well-being, and that is an outcome that helps everyone. Patient advocates have been quite vocal that remote care is working and that it should continue. Patients find the ability to access services easier in many instances, though it is balanced against the recognition that not everything should occur remotely. While an appropriate balance is being established, respecting the desire of patients to continue using remote care should occur.
MATTHEW FISHER General Counsel at Carium | Twitter:@Matt_R_Fisher
Healthcare events do not occur solely within the walls of a healthcare organization but throughout every individual's life. Facilitating interactions without requiring an individual to schedule an in-person visit can work e ectively for everyone. Using remote monitoring as an example, if an individual collects and transmits information about themselves that is collected as a part of daily life, a more accurate snapshot of that individual's life can begin to be developed. Additionally, if a bigger set of data is created, then the individual's care team can spot trends that could indicate the emergence of an issue and begin an intervention before the issue becomes acute.
Health care events do not occur solely within the walls of a health care organization… but throughout every individual's life. Facilitating interactions without requiring an individual to schedule an
in-person visit can work e ectively for everyone.”
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Matt Fisher is an expert in health law, healthcare compliance, HIPAA, digital health, and telehealth. He is currently the general counsel for Carium, a company that o ers flexible telehealth and remote patient monitoring platform that enables providers to deliver relationship-based, digital care at scale across multiple clinical specialties.
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Obstacles in Creating a 360° View of Patient Data
More Complete Patient Understanding Through Shared Data Payers and providers are rich with data, but it's not su iciently leveraged. There are too many gaps, disconnects, and misalignments. Additionally, payers and providers see patients—and their risks—di erently. But imagine the impact if we were able to move the definitions closer together: more e ective population health strategies, seamless authorizations, better customer experience, among other opportunities. To do this, payers and providers need to share data. Merging will require diligent focus as the historical systems and structures are a puzzle that will need to find a way to fit together. In addition, there are philosophical, regulatory and strategic questions that should be reconciled between the parties such as: How do we share population data in a HIPAA-compliant way? How will we use the merged data to create a more holistic view of patients and populations? Can we trust the data? How accurate is it? How do we prioritize where to focus our e orts? Committed interest, time, and technical expertise could close the data gap. But first, there needs to be an agreement that patient outcomes come first. By coming together to support this shared goal, payers and providers will improve their understanding of populations and their risks.
47
Data standardization
44
Technical interoperability
44
Poor shared data quality
Statistic Source: "EHealth Initiative Releases Survey on Onc and CMS Final Rules." Executives for Health Innovation, 11 Nov. 2020.
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Combining Payer and Provider Data to Solve the Blind Spots
STEVE RUBIN Population Health Analytics Consultant, Hennepin Health
While there are some organizations that are much better than others at getting value from data, as an industry, healthcare has a long way to go before reaching the point of diminishing returns from investment in data and analytics. The combination of payer and provider data solves the blind spots of the data sets in isolation. For payers, they are missing the clinically rich information available in Electronic Health Records (EHRs), such as lab results, orders, clinical notes, and vital signs. For providers, they are missing much of the information about healthcare received outside of their systems. Health
Information Exchanges can help solve some of those gaps, but universal participation is not the norm. A model derived from a blend of claims and clinical data would likely be more accurate in identifying risk than a model that uses less complete data. Some have already started evolving toward that with enhanced clinical codes flowing through claims and EHRs that can ingest outside data to get a complete view of patients' risk drivers.
The combination of payer and provider data solves the blind spots of the data sets in isolation … a blend of claims and clinical data would likely be more accurate in identifying risk than a model that uses less complete data."
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Steve Rubin is an analytics expert with more than a decade of healthcare experience. Hennepin Healthcare is a Minnesota-based healthcare system of care with the mission to ensure access to outstanding care for everyone.
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How Technology is Bridging the Gaps in Healthcare
JOHN LYNN Founder and Chief Editor at Healthcare IT Today | Twitter:@healthcarescene
Technology has bridged the communication gap between patient and provider. Even the senior population has proven that they can use technology as part of their care. Prior to the technology we have today, we had to do episodic visits in the o ice. Technology is turning that paradigm on its head as care for a patient, collecting patients' health info, and influencing a patient can happen 24/7 and not just in episodic visits to the clinic. The other advantage of technology is that it can scale to the problem. We don't have enough clinical professionals to be able to monitor all patients constantly. However, technology can
scale to that problem and escalate patients to humans as human intervention is necessary. Without technology, we couldn't even consider this type of approach to care. Technology may also be able to fill the data gaps in healthcare records—but first comes the need to broach the trust gap between payers and providers. If these two groups were to combine their data to accelerate patient understanding, it could have an unprecedented impact on population health. After all, the core of tracking and impacting a patient is based on the data. Without the data, you can't improve the health of a population.
Technology may also be able to fill the data gaps … between payers and providers. If these two groups were to combine
their data to accelerate patient understanding, it
could have an unprecedented impact on population health."
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John Lynn is a recognized healthcare technology thought leader. He regularly shares his insights in Healthcare IT Today, an online publication that provides Healthcare and Health IT commentary and answers the unasked questions about current healthcare trends.
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We Can Help Bridge the Healthcare and Technology Divide
Now is the time to bridge to better health outcomes. We must build programs and services that improve people’s physical and financial health while supporting the needs and priorities of both providers and payers. There's no singular blueprint for how providers and payers should operate. However, we do know population health e orts are stronger when providers and payers collaborate and keep patients at the center of their combined e orts. Still, improving population health isn't easy. Whatever your barriers, Concord can help bridge from current state to future state. We're a business consultancy that solves problems through strategy, design, and, most importantly, technology.
CONTACT US Concord | health.concordusa.com 952.241.1090 info@concordusa.com
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