Op-Ed: Forward thinking health plans? Look for the guys with the white hats

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The public noise about health care reform has painted the parties involved in broad brush strokes that tell  consumers which in the fray are the good guys and bad guys. News reports have for so long vilified health insurers that they’re overlooking the forward thinkers who are actively seeking the white hat role and using their heft for real and positive change.

With the near-term incentives to spur adoption of EMRs and subsequent implementation of clinical decision support to make those EMRs “meaningful”, health plans have a perfect opportunity to improve their value. I already see that happening with our health plan customers who have used additional means to improve their populations’ health, such as personal health records, disease management, and other strategic initiatives.

Reform initiatives — and plain old common sense — are trying to pivot provider compensation away from volume of care to focus more on positive outcomes, and as a result, never before have the interests of the insurers and insured been so aligned. Everyone involved would benefit from better treatment outcomes and lowered costs. The tools to accelerate that alignment are available now and payers can facilitate and accelerate the move.

Analyzing available data to better understand the populations they manage will help health plans and other payers be ready to really step up to the white hat role, when the flood of clinical data increases as a result of the systemic implementation of EMRs.

For example, a plan participant who receives a message from his or her provider with up-to-the-minute accurate, personalized information at the point of care is far more likely to modify behavior, experience a “teachable moment” and adhere to treatment than one who receives a generic message two months after the visit to the physician’s office or pharmacy. So why not leverage available data to promote this potentially life-saving scenario?

As we in the analytics world understand well, it’s the not the shortage of data that’s keeping payers and providers from achieving better outcomes and lowering costs. Rather it’s the wealth of data coupled with only primitive means of accessing and utilizing the data. On top of that, it is not a lack of standards that limits accessibility to data, but the abundance of data standards that are not harmonized. The abundance of data will escalate exponentially when EMRs, PHRs, smart medical devices, and other data-generating elements realize critical mass in the marketplace.

What are we seeing more forward-looking payers doing to manage the data and standards that have and will continue to present such a challenge?

First, they’re defining what they do and don’t know about their populations. Digging into the details of a population involves complex layers of analytics, an undertaking that is difficult for most payers because of the vast differences between clinical data and claims data. That said, the pay-off is significant. Even small changes in how payers analyze their claims and other health care data can make vast improvements in adherence. A more complete and layered view of patient populations can move health plans from basic risk stratification to meaningful participant interventions, achieving positive changes in the managed populations.

Second, they develop analytics strategies that can mature from data that’s available now to data that will be available over the next three to five years.  It only makes sense to walk before you run, but walking earlier rather than later will gives them a competitive advantage.

Third, they use their power to positively influence the availability of clinical data and demand better tools to leverage the data to ultimately facilitate better care at lower costs. In short, they put on that white hat and embrace the role.

Richard Noffsinger is CEO at Anvita Health, a San Diego-based health care analytics firm.

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10 replies »

  1. Having been on the payor side and having spearheaded the use of analytics (e.g., ETGs, ERGs) to provide information to our providers; and also being a provider, let me assert this. Payors are about cost, and providers are about care. The data regarding care and quality need to originate and rest with providers for at least two reasons: 1)the data are timely and can be applied to the patient at the point of service; 2) the payor data is claims based and at least 2 payment cycles behind the point of care. Had managed care heeded the vision of Paul Elwood, we might not be in this current predicament.

  2. To CT Doc,
    Would really like to have a conversation with you. Pls send your contact info: dringalls2@aol.com.
    Thnx, Don (a former Hartford and New Haven resident, working in healthcare)

  3. Clearly unbridled cynicism and negativity is in no short supply. The President has championed a public plan as a way to keep insurers honest (by implication they must be dishonest). While many for profit insurers have worked to fulfill thier mission and build shareholder value, as many not for profit health insurers have sought to innovate learn from the massive datas they collect how best to provide care and how to do so at the lowest cost to the consumer. Here in Massachusetts which leans far to the left carriers such have Harvard Pilgrim Healthcare have been at the forefront of innovation. That they exist in a system which has historically rewarded the volume of care rather than quality does not (in the President’s opinion) make them dishonest or unconcerned with outcomes

  4. Deron, I’m all about positive thinking and optimism. However, reform does not necessarily imply that we hand the keys to commercial payers. As a matter of fact, I thought that most of the proposals out there are aimed at increasing regulation of commercial insurers and/or providing an alternative public plan. The payers have been empowered to make health care decisions for decades and there is nothing in their track record to indicate the existence of “white hats”.

  5. One thing I do know is that real reform will not be driven by naysayers. Richard, I thought your post was a good one. You have illustrated an area where we can really make progress. The negative responses, while they are somewhat justified because of the “bad apple” health plans out there, are not helping the reform effort. We have to stop living in the past, and start deciding what we want the future to look like.

  6. CT IPA Doc, it’s much better than that.
    Guess who is going to be responsible for “the flood of clinical data” which will increase “as a result of the systemic implementation of EMRs”. You are. You will actually be made to collect all this “flood” and send it to insurers, at no cost to them and at significant cost to you and the tax payer (re stimulus).
    The result? “Fine tune” reimbursements to physicians and benefits to patients to promote “positive outcomes”.

  7. Instead of wasting my time and yours collecting and analyzing data to prove the value of my least valuable service (an office visit) how about paying me for those services that actually provide value (telephone calls, e management etc…)

  8. What universe are you talking about? Out here on the right coast (New England) most health plans don’t want to share squat with providers, as far as data goes. All they seem to want to do is drive down unit reimbursement to PCPs and specialists. Requests by providers and provider organizations for data are seen as (1) costly additions to admin costs and (2) a way to empower physicians, which must be avoided at all costs. Got to keep those docs disaggregated and in the dark, datawise. so we can keep on screwing them. Quality? A good game we talk up to employers while we barely giving it lip service to most physicians. Supporting provider collaboration on quality? Must be avoided at all costs less those docs start to get empowered and want more and more data. I quess I’ve tried to negotiate too many HMO deals and my cynicism is showing.

  9. Well, I think it all comes down to the definition of the term “positive outcomes”. This is being tossed around as the holy grail of reform. Provide better treatment at lower cost. Is it that simple, really?
    What if treatment A is very painful, lasts for 5 years and restores 85% of quality of life, while treatment B is less painful, lasts 1 year and restores the same quality of life, but costs 10 times more?
    Which one will be deemed a “positive outcome” by the insurer and which one will the patient prefer?
    I bet the insurer and patient/provider interests will not be as well aligned in this case as we assume.
    Considering that, by definition, cost is the ONLY driver for insurers, I would be very hesitant in allowing them to both define the rules of the game and enforce said rules on all of us.

  10. Why do I want the insurance company to manage the data? Sounds like a disaster no matter the color of their hats. Are we suggesting that we want payers to manage the clinical care as well?
    Someone has to teach providers the importance of using data to improve quality. They are the ones who have to use it and have to understand how it improves their practice of medicine.
    The ability to do this has existed for decades, the understanding of why and the will to do it (not least of all the cultural willingness to put systematic data properly analyzed ahead of intuition and “experience”) is what has stood in the way of providers doing their job the best way possible.