As Opportunity Knocks, Will you Listen?

By Kelly Monical
11:00 AM

They say that less is more, but sometimes more is in fact more. With the existing and emerging technology found in today's healthcare environment, healthcare organizations are able to collect, interpret and react to more data about patients and their care than they ever have before. This ability to access and leverage large volumes of data is shifting healthcare from a predominantly reactive endeavor to a more proactive one, and supporting more targeted interventions that improve the quality of patient care as well as its efficiency. In this context, more data means more tangible benefits for healthcare providers, payers and patients in terms of better patient outcomes.

Health Reform is Spurring Data Use
The Affordable Care Act (ACA), Meaningful Use (MU) and other healthcare reform initiatives are driving the industry toward more interactive data use. Health plans, for example, must collect large volumes of data, including risk scores, prior admissions, number of medications, number of chronic conditions and frailty indicators, to support compliance with federal requirements and ensure the accuracy of risk profiles.

A valuable byproduct of all this mandatory data collection is the ability of a health plan to not only see what care its members receive but what care they should receive but do not. For example, if a Medicare Advantage member has multiple visits to several different cardiologists but no diagnosis for hypertension or other cardiac issues, there is a potential gap between the care the patient needs versus the care he or she is receiving. These gaps present opportunities to improve care and thus transform patient health.

Taking this information one step further, health plans can begin to close identified care gaps. By visiting targeted patients in their home or reaching out to them through the telephone and conducting assessments, health plans can create a holistic picture of a patient, identifying the various doctors the patient has seen in the past year, the number of medications the patient is taking, the nature of the patient's medical condition and so on. This patient portrait is quite valuable because it shows a comprehensive picture of the patient that a single healthcare provider cannot often obtain.

Fostering an Unlikely Partnership
Now imagine if a health plan partnered with a group of healthcare providers and connected patients with known care gaps with providers who could close those gaps. In these cases, the health plan could share information from the patient profile with everyone involved in the patient's care. Providers could use this information to get patients into care and target the care they provide, ensuring both quality and efficiency.

More specifically, this partnership could result in coordinated activities that further enhance care, such as regular appointments, timely medication refills, consistently-performed lab work and other actions that support chronic care management. Such collaboration could also reduce the likelihood that a patient would need acute care. Avoiding this type of care is not only better for the patient's long-term health; it is also a less expensive approach to care delivery. Consider the example of a senior patient with untreated asthma. Through data analytics, the health plan could identify this patient and begin to gather comprehensive information about his or her current care. The physician practice could then engage with the patient to provide targeted care, and the patient could shift from needing emergent care to proactively treating his or her chronic condition.

Unfortunately, collaboration between payers, providers and patients is not the norm. Some providers remain skeptical about the motivations of health plans in developing patient profiles and are concerned that information is gathered merely as a way of enhancing risk profiles. Although a health plan is certainly interested in developing the most accurate risk profile possible, that is not their sole purpose in leveraging patient care data. It is in the health plan's best interest to improve the long-term health of its members and using data about care gaps to transition patients into care is the best way to accomplish this goal.

While a partnership between payers, providers and patients may seem like a pipe dream, it is starting to become a reality. In fact, the changing dynamics of healthcare are pushing this type of partnership to the forefront, and payers and providers must begin to work together in order to meet the requirements of health reform. Keeping an open mind to such partnerships will help both payers and providers effectively leverage vast amounts of data to realize better quality and enhance patient outcomes.  

Kelly Monical is president of Senior Care at Outcomes Health Information Solutions.