Unified Patient Data: A Catalyst to Improve Outcomes for Special Need Plans

In 2004, the introduction of special needs plans (SNPs) marked a pivotal moment for payers serving Medicare Advantage populations. It sparked a dynamic approach to addressing the unique requirements of high-need beneficiaries. Over the years, we've observed an uptick in payers moving into the SNP market, seeking to provide tailored healthcare solutions.

SNPs play a crucial role in providing care for special needs populations, but they face significant data challenges that hinder their ability to modernize their practices and achieve success. The complexity of data collection, inconsistent reporting processes, and fragmented data systems are just a few of the obstacles SNPs must overcome to achieve success.

This article explores these challenges, evaluates how SNPs can use a data and analytics platform, and solutions for harnessing data, to provide comprehensive patient-centered care, improve health outcomes, and reduce costs for SNP members.

The SNP Data Challenge

Streamlining the new model of care presents SNPs with a host of data challenges. SNPs rely on disparate software and data systems that lack seamless interoperability and integration, creating a fragmented data landscape. This approach is ineffective, resulting in incomplete or missing data, impeding care coordination, patient outcomes, and rendering it challenging for SNPs to leverage data for critical decision-making. 

Here are some data challenges SNPs typically wrestle with:

• Data Silos → Fragmented Patient Records: Aggregating, curating, and making use of massive amounts of data from myriad disparate clinical and non-clinical sources—both inside and beyond the health system’s four walls—such as EHRs, claims systems, pharma, labs, devices, CRMS, consumers, SDoH and industry data (ADT, etc.).
• Lack of a Standard Data Format: There are over 40 SDOs (standard developing organizations) operating in US healthcare that are accredited by the American National Standards Institute (ANSI) and the International Organization of Standardization (ISO). The integration of data that adheres to so many differing standards is a mind-numbing task for SNPs.
• Maintaining Skilled IT Staffing to Prevent Burnout: The scarcity of data science,  integration experts, and skilled IT personnel is a growing problem. Healthcare data aggregation requires experts who are well-versed in IT and healthcare standards, and also have the leadership skills and vision to succeed at such complex, mission-critical initiatives. However, it’s difficult for decision-makers to find and recruit talent who can work on similar initiatives across broad business use cases and deliver them on time and on (or under) budget.
• Data Security: Healthcare in the US is under pressure to improve data privacy and security. This is due to the high volume of sensitive personal information, such as medical records, that are collected and stored by healthcare providers. Balancing HIPAA regulations and regulatory compliance can be tough, as providers must trust their integration initiatives and ensure that any information exchange will uphold and protect the patient’s data rights. Fulfilling these regulatory requirements requires compliant, and often certified, HIT systems. Building such systems from scratch or updating existing systems adds to the total IT cost of ownership—not to mention the risk of not getting compliance right.

Using Data Management and Analytics to Tackle SNP Challenges

To address data challenges and modernize Medicare practices, SNPs must use a data platform to streamline data collection, foster consistent reporting, and seamlessly integrate disparate systems. Adopting a data platform means that SNPs will be able to collect and use real-time, accurate, and actionable data, which are essential in improving care coordination and delivering better healthcare outcomes. The following five components of the digital transformation landscape can help SNPs overcome these data challenges:

1. A data platform to ingest data from all sources
2. An AI-enhanced point-of-care provider engagement tool to provide the right data in the right setting at the right time, displaying potential care and quality gaps to drive optimal medical interventions
3. A care management tool with customizable workflows and AI-automated documentation to assist care managers in providing care on a day-to-day basis
4. High-end risk and quality analytics equipped with AI-enhanced predictive modeling to identify high-risk populations, and decision support to help allocate resources accordingly
5. Provider performance and contract management tools to identify underperforming providers in need of support

Payer-Provider Collaboration: Essential to SNPs’ Success

Payviders (as we know, a business model that fuses payers and providers) offer a more extensive scope for payer-provider collaboration, unlike arrangements where payers and providers remain distinct and often at odds. Additionally, payvider organizations are uniquely positioned to break down data silos and use unified data to improve health outcomes.

Enrollments in Medicare Advantage plans have witnessed substantial growth since 2004. To succeed in the health plan market, payers need to consistently onboard new providers across various specializations and locations.

Given that both payers and providers share a primary focus on enhancing care outcomes and reducing care costs for their members and patients, an integrated payer-provider model featuring data-sharing capabilities becomes crucial for success. This model can give rise to an expansive network of care providers, enabling payers to offer in-network benefits to members as well.

The Road Ahead

The journey forward hinges on driving payer-provider collaboration and leading-edge data and analytics technology. By adopting innovative solutions and cultivating strategic alliances, the challenges associated with SNP care delivery can be overcome.

Improved clinical and claims data management presents significant opportunities for SNPs. To achieve success, however, SNPs must overcome the challenges posed by diverse data collection and reporting processes, fragmented data systems, and limited access to real-time, accurate data, which can hinder the delivery of quality care outcomes. Utilizing a proven data and analytics platform enables strategies and solutions that address these challenges, streamlining data collection and sustaining quality care outcomes. SNPs that implement strategies to enhance data management and leverage data insights are well positioned to make evidence-based healthcare decisions that positively impact their special needs populations. Innovaccer, with its best in KLAS data platform, analytical, and care management solutions helps health plans deliver on the promise of value-based care. The Innovaccer platform fosters tight collaboration and connectivity among health plans, providers, and members. By unlocking the power of data with the #1 Healthcare Data and Analytics Platform, health plans gain a 360-degree view of their members, reducing IT costs and enhancing care quality.

With a robust data and analytics foundation, continuous learning, automated workflow enhancements, and model of care support, Innovaccer offers a tailored and AI-enabled suite of modular solutions, geared toward driving special needs plans to success.  

As healthcare continues to evolve and modernize, the potential to enhance the lives of high-need beneficiaries through effective, efficient, and compassionate care can become reality.