Health IT

How can Healthcare Payers Patch Patient-centric Care Together?

Sandeep Gupta
Thu 14 June 2018

Although payers are fairly young in the healthcare dynamics, they have been somewhat uniquely positioned in the transforming value-based healthcare. Payers are distinct stakeholders in healthcare, and provided the rapid transformation, healthcare needs someone to cut through the complexity of the current system, demand true value from providers, and make patient-centric care a reality instead of a discipline.

And talk to anyone on the payer or the provider side of healthcare, you’ll find several instances where they both agree: getting the spiraling cost of healthcare under control, focusing on the quality of care, setting goals for improvement, and tracking performance against those goals. Unfortunately, the agreement will end there- because when it comes to seeking logistics behind the “what” and the “how”, the answers are all over the place.

Often the things that are missing in healthcare end up making the difference, and so is the case with patient-centric care. Payers may put in all their efforts into improving their members’ health, but finding that missing piece of information is the biggest challenge of it all- especially as healthcare digitizes. And then there are audits, reviews, HEDIS, Star ratings. No matter what, access to the right healthcare data- including clinical data- at the right time has become critical for payers.

The conventional route: chart retrieval from providers

The traditional process a payer undertakes to bridge the gaps with clinical data is to acquire member charts from providers- a process demanding hours of manual labor! The process of acquiring these charts via some third party is expensive as well- costing as much as $12 per chart and lasting 15 days on average. Obtaining relevant clinical records, reviewing them, and extracting reliable results out of them is already a complicated process, further tangled by the lack of interoperability among EHRs.

Then, of course, is the need to review the charts to identify the gaps in care and provide member-level decision support to providers at the point of care. There could be inaccurate or incomplete information and documentation, leaving you to wonder if you’re even looking at the right member.

Topping it all, there are 81 HEDIS measures spread across 5 domains and CMS Star ratings governing the performance of payers, making it important to retrieve charts effectively- not to mention quickly.

Untangling the complicated web of chart retrievals

The best possible way to simplify the process is to enhance connectivity among healthcare data systems and automate the chart retrieval processes. The biggest challenge is that the data systems in healthcare do not communicate. If simple but robust connection mechanisms are leveraged, the time to acquire data could be greatly reduced. Be it patient charts, physician notes, or lab orders- all of these have to be brought together on a unified healthcare data platform to create unique, longitudinal records representing each member.

Another challenge that stems out of disparate data sources is the quality of data. Ever since the care continuum expanded beyond the four walls of a hospital, patients have been receiving care across multiple settings which results in different systems storing different data in different formats. Data should only be aggregated when it is standardized and reflects as minimum number of redundancies and errors as possible.

And ultimately, the analysis. Often, healthcare executives end up analyzing the data they have instead of the data they need. The key is to know what data has to be analyzed to propel the organization towards their value-based goal. So while it may be a little cumbersome and painful, analytics that are built for you are essential.

You may also like: How can Healthcare Data Analytics Redefine Care?

Ensuring better patient outcomes

We cannot imagine a value-based healthcare without patient-centric care. It takes the collaboration of both providers and payers to improve the health of patients in their network and deliver optimal financial outcomes. The Centers for Medicare and Medicaid Services has nudged these two significant stakeholders by defining several measures along with their thresholds to evaluate patient health:

  • Length of stay
  • Hospital admissions per 1000
  • 30-day and 90-day readmissions per 1000
  • ED visits per 1000
  • Patient satisfaction scores
  • Number of preventive screenings

To find the true numbers to these measures, it’s important that the claims data owned by payers and clinical data from providers is put together and analyzed. And more importantly, the analyzed information should be available to providers at the point of care– right when the patient visits them.

This is another challenge that is fueled by the lack of interoperability. The network providers don’t have the access to patient information, and payers fail to drive better clinical outcomes for patients because of little information. Payers need to keep the physicians engaged and aware to improve patient-centric care as they are the first touch point for a patient navigating the care continuum. Prompting information like what is the patient’s risk score, how many times did she visit the ED in the last three months, or has he missed any screenings- could be helpful for physicians.

Such prompts and alerts could be instrumental in improving clinical documentation and generating reimbursements as well. If payers could ensure the entire patient record is accessible to providers, they can take a look at the codes that were punched in, find out whether some of them were dropped or keyed in wrong, and they could either be filled or replaced with more accurate ones.

You may also like: Clinical Documentation Improvement: The Building Blocks of Modern Healthcare

It all begins with making data accessible

Payers direct the bulk of healthcare dollars and they can be immensely important in understanding different segments of their members, create innovative solutions, and help providers gain the action-oriented information they need to address the needs of their patients. But before they do any of this, payers need to understand how to work with data and gain the insights they need to create changes- something which will not happen if the processes around us are holed with inefficiencies. It’s a lot of data and a lot of potential- all that remains is driving transformation with technology intelligently and effectively to transform healthcare.


To learn more about how efficient chart retrievals can enhance Star ratings and HEDIS performance, get a demo.

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