Traditionally, hospitals have thought as payors as competitors, or the enemy, says John Halamka, MD, senior vice president of information systems and CIO of Beth Israel Deaconess Medical Center in Boston. With mounting pressure from healthcare reform to coordinate patients' care throughout the continuum of care, hospitals and health systems will need to partner with payors to access healthcare analytics and manage population health.
In 2011, BIDMC partnered with health insurer Network Health on an e-discharge program to improve the coordination of care for patients. Under the program, with patients' consent, BIDMC automatically sends patients' information, including their electronic discharge summary, labs, history and physical, to Network Health upon patients' discharge from inpatient care or the emergency department. The insurer then analyzes the information and reaches out to patients to ensure they follow post-discharge instructions.
Evolving role of the payor
In Massachusetts, the creation of the New England Health Exchange Network in 1997 sparked greater partnership between payors and providers, Dr. Halamka says. "[Establish] relationships so you trust each other as collaborators," he says. "Suddenly it isn't you against the world; it's the community working to solve problems collectively."
Hospitals and payors are realizing that to control costs and quality effectively, they will need to work with each other not just on insurance plans and claims data, but on the long-term management of patients' health.
"The relationship is changing into more of a partnership, and partnership and planning are the best ways to address cost, quality and positive outcomes," says Mary McKendry, vice president of clinical affairs at Network Health.
Payors are in a unique position to help hospitals manage population health because they have access to data from all patients' healthcare visits, whereas a hospital may have access only to patients' inpatient or ED visits, and a primary care physician may have access only to patients' wellness visits. "Traditionally people have never thought of payors as [having] comprehensive longitudinal data, but they are paying claims to every party they see, so they have one of the clearest views of all the care you are consuming," Dr. Halamka says. BIDMC aims to leverage Network Health's data capabilities to help manage patients' health after discharge and beyond.
Payors can benefit from this relationship, too, because preventing readmissions can lower healthcare costs and providing additional support for patients increases satisfaction. "There's a lot of value from collectively being able to exchange information and being able to make better healthcare decisions," says Peter Bristol, vice president and chief technology officer for Network Health.
Managing population health
When Network Health receives clinical information from BIDMC, it analyzes the data and assigns it to individuals within the organization who are best equipped to reach out to different patients. "We evaluate whether someone needs to go into a safe transitions of care program or needs a higher level of case management or follow-up from an outreach worker, or just a phone call," Ms. McKendry says. For example, Network Health calls patients to confirm they scheduled follow-up appointments with the necessary physician and filled their medications.
Network Health's engagement with patients lasts beyond immediate post-discharge instructions and into patients' long-term self-management. The insurer examines patients' reasons for visiting the ED, for instance, to determine if there was a more appropriate care alternative, such as an urgent care center.
These efforts aim to not only prevent one readmission, but to also change people's healthcare decisions that can lead to lower costs and better health overall. "We work with people holistically," Ms. McKendry says. "We don't address just why they went to the emergency room, but what are their total health needs." Network Health may follow up with an ED patient for three to four weeks after discharge, and up to six months for a discharged inpatient with more complex needs.
Future relationships between payors and providers
With the challenge of lowering costs and improving quality, it is unlikely these types of data-sharing partnerships between payors and providers will be short-lived. In fact, Dr. Halamka thinks payors' role as data aggregators may become more prominent over time as hospitals and physicians come to rely on accurate, meaningful data to design healthcare services.
"In a world of healthcare reform, payors [will be] less about claims processing and more about data aggregation and analytics — predicting who will be sick, who needs what innovation," he says. Similarly, hospitals will be less about solely inpatient care and more about preventive and wellness services that support patients' long-term health. Together, hospitals and payors can learn from each other and leverage each other's strengths to create the greatest healthcare value.
"The next five years are going to be the most interesting in healthcare in our lifetime," Dr. Halamka says. "We have a combination of meaningful use stage 2, ICD-10, healthcare reform, value-based purchasing, patient-centered medical homes. It will require a foundation of IT. And rather than get scared, try to build communities of collaborators; we'll be stronger if we approach challenges together."
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In 2011, BIDMC partnered with health insurer Network Health on an e-discharge program to improve the coordination of care for patients. Under the program, with patients' consent, BIDMC automatically sends patients' information, including their electronic discharge summary, labs, history and physical, to Network Health upon patients' discharge from inpatient care or the emergency department. The insurer then analyzes the information and reaches out to patients to ensure they follow post-discharge instructions.
Evolving role of the payor
In Massachusetts, the creation of the New England Health Exchange Network in 1997 sparked greater partnership between payors and providers, Dr. Halamka says. "[Establish] relationships so you trust each other as collaborators," he says. "Suddenly it isn't you against the world; it's the community working to solve problems collectively."
Hospitals and payors are realizing that to control costs and quality effectively, they will need to work with each other not just on insurance plans and claims data, but on the long-term management of patients' health.
"The relationship is changing into more of a partnership, and partnership and planning are the best ways to address cost, quality and positive outcomes," says Mary McKendry, vice president of clinical affairs at Network Health.
Payors are in a unique position to help hospitals manage population health because they have access to data from all patients' healthcare visits, whereas a hospital may have access only to patients' inpatient or ED visits, and a primary care physician may have access only to patients' wellness visits. "Traditionally people have never thought of payors as [having] comprehensive longitudinal data, but they are paying claims to every party they see, so they have one of the clearest views of all the care you are consuming," Dr. Halamka says. BIDMC aims to leverage Network Health's data capabilities to help manage patients' health after discharge and beyond.
Payors can benefit from this relationship, too, because preventing readmissions can lower healthcare costs and providing additional support for patients increases satisfaction. "There's a lot of value from collectively being able to exchange information and being able to make better healthcare decisions," says Peter Bristol, vice president and chief technology officer for Network Health.
Managing population health
When Network Health receives clinical information from BIDMC, it analyzes the data and assigns it to individuals within the organization who are best equipped to reach out to different patients. "We evaluate whether someone needs to go into a safe transitions of care program or needs a higher level of case management or follow-up from an outreach worker, or just a phone call," Ms. McKendry says. For example, Network Health calls patients to confirm they scheduled follow-up appointments with the necessary physician and filled their medications.
Network Health's engagement with patients lasts beyond immediate post-discharge instructions and into patients' long-term self-management. The insurer examines patients' reasons for visiting the ED, for instance, to determine if there was a more appropriate care alternative, such as an urgent care center.
These efforts aim to not only prevent one readmission, but to also change people's healthcare decisions that can lead to lower costs and better health overall. "We work with people holistically," Ms. McKendry says. "We don't address just why they went to the emergency room, but what are their total health needs." Network Health may follow up with an ED patient for three to four weeks after discharge, and up to six months for a discharged inpatient with more complex needs.
Future relationships between payors and providers
With the challenge of lowering costs and improving quality, it is unlikely these types of data-sharing partnerships between payors and providers will be short-lived. In fact, Dr. Halamka thinks payors' role as data aggregators may become more prominent over time as hospitals and physicians come to rely on accurate, meaningful data to design healthcare services.
"In a world of healthcare reform, payors [will be] less about claims processing and more about data aggregation and analytics — predicting who will be sick, who needs what innovation," he says. Similarly, hospitals will be less about solely inpatient care and more about preventive and wellness services that support patients' long-term health. Together, hospitals and payors can learn from each other and leverage each other's strengths to create the greatest healthcare value.
"The next five years are going to be the most interesting in healthcare in our lifetime," Dr. Halamka says. "We have a combination of meaningful use stage 2, ICD-10, healthcare reform, value-based purchasing, patient-centered medical homes. It will require a foundation of IT. And rather than get scared, try to build communities of collaborators; we'll be stronger if we approach challenges together."
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