Leveraging Shared Data Infrastructure: How PSHPs Can Stay Ahead

In today's fragmented healthcare system, patients and providers alike face unnecessary friction.

This friction is a result of the way health insurance plans and health delivery systems typically interact, which is typically based on leveraging their respective market power in complex negotiations to secure better financial outcomes. Health plans bring actuarial and claims data to the table; health systems bring clinical and cost data. It’s less about sharing data and more about using it to win.  

Provider-Sponsored Health Plans (PSHPs), health insurance plans owned and operated by healthcare delivery systems, have an opportunity to take a  fundamentally different approach. Unlike other commercial insurers, PSHPs should be uniquely positioned to leverage  payer and provider datasets under one organizational umbrella, allowing them to integrate benefit design, network management, care delivery, and financial systems in ways that conventional health plans cannot.

Now imagine a health plan where coverage decisions are informed by clinical outcomes data, where utilization management is replaced by intelligent plan design, where care management programs identify high-risk members before costly complications arise, and where network configuration actively guides members to the highest-value care settings. This is happening right now in well-designed PSHPs, where the power of shared data infrastructure is transforming both insurance administration and the economics of healthcare.

Breaking Down the Data Walls

Traditional healthcare financing has long suffered from a fundamental disconnect: health plans and healthcare providers operating in separate universes, with misaligned financial incentives and each with their own fragment of the member/patient story. While PSHPs have an upper hand over other health plans in numerous ways, perhaps their most powerful advantage lies in their ability to break down these data walls. When the insurance plan and delivery system operate under unified governance, and more importantly, share the same data infrastructure, systemic transformation becomes possible.

Consider how a PSHP approaches benefit design and population health management. Unlike commercial insurers who design benefits with limited clinical input and providers who develop care programs with limited understanding of coverage constraints, PSHPs can create truly integrated models. They can design benefit structures that preferentially cover high-value services with lower cost-sharing, while simultaneously ensuring their delivery system is equipped to provide those services efficiently. 

Their unified data enables them to create risk stratification models that incorporate both claims and clinical data, identifying emerging high-cost member cohorts much earlier and designing targeted benefits and interventions for them. For example, a PSHP might identify members with both rising A1C levels and medication adherence challenges, then design a value-based insurance design with reduced or eliminated cost-sharing for diabetes medications alongside a tailored disease management program.

The Power of Predictive Insights

But shared data infrastructure isn't just about seeing the full picture; it's about operationalizing insights across both health plan operations and care delivery. PSHPs should be leveraging their unified data systems to redesign insurance products and provider payment models simultaneously.

A well-designed PSHP might analyze its claims data and discover that a significant percentage of low-acuity emergency department visits are occurring among members who live in specific neighborhoods with limited access to urgent care. 

Rather than implementing traditional utilization management barriers (which often frustrate both members and providers), the PSHP can respond holistically: adjusting their benefit design to reduce copays at in-network urgent care centers, expanding their network by making targeted investments in urgent care access in underserved areas, implementing a telehealth triage solution covered at 100%, and creating aligned incentives for their employed physicians to offer extended hours, all while precisely measuring the ROI of these interventions through their integrated data platform.

Turning Data into Action

The real power of shared data infrastructure lies not just in collecting information, but in making it actionable to the right individual at the right time. PSHPs can use their integrated systems to create seamless experiences that were impossible in fragmented systems. When a doctor orders tests or refers to a specialist, the system should automatically check coverage, estimate costs, and even help schedule appointments-all while ensuring the care plan aligns with evidence-based guidelines.

This real-time coordination is transformative. It means fewer missed appointments, better adherence to treatment plans, and ultimately, better health outcomes with a lower total cost of care. For providers, it means spending less time on paperwork and more time on patient care. For patients, it means a healthcare experience that finally feels coordinated and personal.

Why PSHPs will Make All the Difference

The economic impact of this integrated approach is substantial. When a PSHP implements an effective shared data infrastructure, even small improvements in health plan operations and care delivery efficiency create significant value across multiple dimensions:

• Reduced administrative overhead: By eliminating redundant workflows, like member-focused care management by the payer and patient-centered care management by providers,  PSHPs can achieve substantial savings through shared services models. This advantage can create price, margin and outcome advantages for PSHPs. 
• Optimized health plan design: When benefit structures are designed with full visibility into care delivery patterns and clinical outcomes, PSHPs can create sophisticated tiered benefits that truly incentivize high-value care. Steering elective procedures to centers of excellence can significantly reduce complications and generate substantial medical cost savings.
• Intelligent network management: With comprehensive data on both quality outcomes and cost efficiency, PSHPs can design provider networks that channel members to highest-value care settings while offering appropriate reimbursement models. Redirecting even a small percentage of specialty care from low-value to high-value providers yields meaningful savings while improving clinical outcomes.
• Proactive medical management: When claims data, authorization requests, and clinical information are unified, PSHPs can systematically identify high-risk members before costly events occur. Each prevented complication or hospitalization represents significant avoided costs. For PSHPs managing members with chronic conditions, sophisticated care management enabled by integrated data can yield substantial medical cost reductions.

PSHPs have built-in advantages over other health plans, but research shows that these operational and market advantages are rarely if ever fully leveraged. We think it’s time for that to change. A shared data ecosystem and a more efficient operational model can create profitable, high-growth opportunities at a time when health systems are facing enormous financial pressures driven by constraints on reimbursement models, rising costs, and an uncertain regulatory environment. Let’s talk about how provider sponsored health plans can finally realize their full potential.

Ready to learn more about building effective data infrastructure for your PSHP? Let's continue the conversation.

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