Best practices for payer health management programs

Real-time data-sharing, targeted reimbursement models increase care quality, efficiency

Health IT tools and more transparent relationships with providers are among the best practices that can help health insurance companies improve health management programs, according to a new report by IDC Health Insights.

"Successful payer and related IT applications managers have many challenges," including "meaningful" member education for patients who are most at risk for 30-day hospital readmissions and those who have costly chronic conditions, Deanne Kasim, IDC's research director, said in the report.

"Health management programs and the supporting IT applications are important tools in supporting emerging reimbursement models--including value-based reimbursement [and] pay for performance--while concurrently increasing the effectiveness and efficiency of care," the market intelligence firm said in an announcement.  

Among the best practices identified in the report:

  • Choosing reimbursement models that make the most sense based on medical conditions and cases, such as bundled payments for higher-cost, definable episodes

  • Creating high-performing, integrated relationships with a coordinated team of providers

  • Implementing IT applications that integrate payer and provider access to data from claims payment, health management programs and provider reimbursement

  • Using IT applications that include predictive modeling and risk stratification tools, consumer experience assessments, evidence-based clinical guidelines and real-time information sharing through a secure portal

Payers are increasingly warming up to the idea of sharing data that was once fiercely guarded. 

MVP Health Care, for example, has moved away from disconnected systems in favor of centralized data. "Otherwise, we'll make less informed decisions from inadequate data," Linda McCann, MVP's vice president of business intelligence, told FierceHealthPayer earlier this year.

Reimbursement models--especially accountable care--are driving the shift: Without integrated data, ACOs will find it tough to measure success

"Health management program managers need to review their overall programs and approaches to view members as a whole patient, rather than independent, soiled episodes of care," Kasim said. 

"It is this fundamental shift in program philosophy ... and related IT application design that will enable care and disease management initiatives to become more efficient, lower expenses and prevent unnecessary readmissions and admissions."

To lean more:
- here's the IDC announcement
- here's the study abstract

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