Healthcare’s Double Personalities Can Bring New Innovations to the Market

Changes in the roles of payers and providers that may make them feel as if they’re in Shakespeare’s The Comedy of Errors require a joint approach to care management and patient analytics.

(Image credit: Dollar Photo Club.) 

Changes to the healthcare market have many of us feeling like we’ve become part of Shakespeare’s The Comedy of Errors. In the play, mistaken identities lead to violence, seduction and one misunderstanding after another. At the end, all is tied up in a bow, as all of the players realize what has occurred, and the characters emerge unscathed and in a better place than before. Healthcare payers and providers are experiencing something similar. Unlike the play, however, happily ever after will require a good deal of work.

Once the province of providers, payers now find themselves directing care initiatives to manage and gain from risk. And once limited to payers, providers now face new financial risks that require them to have a clear picture of patient health throughout their lives, not just when they walk into the their offices with a health condition.

Just as The Comedy of Errors works itself out in the end once everyone figures out each other’s true identities, so too are payers and providers working it out, by redefining their roles and collaborating to create an integrated experience that helps manage patients through every step of the care continuum.

By gaining visibility into the other half of the healthcare system, payers and providers together can increase patient satisfaction, reduce visits and improve overall health, all of which minimize financial risk. And that’s something from which everyone benefits.

Changes Require a Joint Approach to Patient Analytics

As payers and providers learn how to better communicate, both sides can benefit from more sophisticated models that support patient health. Today’s systems—enterprise systems on the payer side and electronic health records on the provider side—must knit together financial, clinical and social data from claims submissions, lab results, demographics and more, to deliver the wealth of information required for finding actionable insights.

For example, payers need to tap into population health data to help providers analyze and understand patients so that they can identify high-risk populations that need to be more carefully managed. This requires open, real-time payer systems that show providers a patient’s holistic health profile at the start of the appointment.

The result: Healthier, happier patients whose medical conditions can be caught and treated before they fall through the cracks.

Working Together to Engage Patients from Start to Finish

Patients want the ability to manage their entire healthcare experience online, from shopping for a plan and paying their premiums and balances, to accessing electronic health records and emailing their providers. That being the case, today’s systems must add capabilities to let payers and providers deliver information in real time and in the right format so that they can meet the customer service expectations set by other digital industries like shopping and banking. Full online access to real-time information and services, that is useable and meaningful, including cost estimators and online coaching, will make for well-informed patients better equipped to complete their treatment plans. As both sides prepare for integrated health plans, this engagement is crucial in capturing the full financial opportunity.

Then, as patients move through the healthcare system, continued engagement will be crucial. Systems used by providers and payers both are keeping patients connected to keep small health issues from spiraling into huge concerns. Payer core administration systems are increasingly providing insights to everything from electronic health records to fitness device data. Through this, they can alert providers about member health issues, and suggest and coordinate care, while providers can coordinate care across teams.

New Ways to Manage Patients

A better engaged patient is a better managed patient, and both providers and payers will realize the benefits. As both sides share responsibility for successful treatment, it will become easier for each party to ensure that financial and clinical outcomes are aligned. This requires being able to analyze patient health together and to benchmark status against a patient’s peers. By sharing management tools, payers will improve the quality of treatment while reducing cost, and providers will be able to better address the new wellness care model. In both cases, the patient wins.

The switch to a shared responsibility and risk for patient health is a challenge for payers and providers, certainly, but with new innovations they can surmount any obstacles of data sharing and timeliness. The result is that together, payers and providers can better predict financial performance while improving patient health and satisfaction.

Right now there’s a lot of confusion over responsibilities in the healthcare space. But just like in The Comedy of Errors, all it takes is for payers and providers to collaborate to bring a happy ending of new ideas and innovations.

Darin LeGrange // Darin LeGrange joined Aldera in October 2012 as President and Chief Executive Officer. Darin has been a market leader in the healthcare IT industry for nearly 25 years, having successfully led the growth efforts of several of the largest and most successful healthcare organizations in the industry. With executive experience spanning complex payer and provider market segments, Darin has spearheaded rapid financial growth in the industry through the development, distribution and delivery of a wide range of technology-enabled, clinical and financial solutions that have included a multitude of consulting and professional services, proprietary software product development, as well as complete business process and IT outsourcing solutions.

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