Organizations struggle in making the transition to care management

New reimbursement methodologies will force providers to move from claims management, requiring technology that enables better care for patients.

As new reimbursement methodologies take hold, healthcare providers and insurers will need to better manage the care of patients, eventually obviating the need for claims management.

However, there’s wide disparity between healthcare organizations’ understanding of the importance of total care management for patients and their ability to actually manage care.

A just-completed survey by Health Data Management finds that nearly half of respondents don’t believe their organizations are effective in managing patient care. By contrast, nearly two-thirds of respondents expect that the ability to manage the full spectrum of patient care will be somewhat to extremely important for their organizations.

Health insurers are already expanding the scope of their business activities to take a more active role in the lives of their members. Respondents to the Health Data Management survey also believe that healthcare providers will need to take on more expansive care management activities, particularly as they assume more risk in value-based care contracts.

The study was conducted by Health Data Management and SourceMedia Research, the research arm of HDM’s parent company. A total of 160 responses, primarily from provider organizations, were received in late 2018.

In general, survey respondents said their organizations realized the importance of making the business transition from a claims-based system to one based on optimizing the health of patients, but current effectiveness in providing total care management lags behind.

For example, only 23 percent of respondents to the Health Data Management survey said their organizations are either very effective or extremely effective in migrating from claims administration to total care management. By contrast, 48 percent of respondents say their organizations are either not effective, not very effective or only somewhat effective in making this transition.

However, these executives understand the importance that total care management will have in the future. Some 12 percent of respondents see this transition as extremely important; 30 percent see it as very important; and 21 percent say that transition is somewhat important to the future of their organizations.

The linkage of this transition will be key for organizations that want to perform well in future value-based care scenarios, respondents said in written comments. “This is a key priority for organizations that want to thrive in the future,” one respondent noted.

“It’s critical for providers and payers to encourage wellness for their patients, to keep healthcare costs down,” another respondent said.

Moving away from claims data to a more expansive data set on patients is crucial in optimizing care, survey respondents noted. “Claims data is so old by the time we get it, it is virtually useless or, worse, wrong,” one respondent noted.

Health insurers are increasingly taking on expanded roles in tracking and trying to improve the care of the people they cover. For example, last year UnitedHealthcare kicked off a program that aims to reward members who commit to certain healthy activity goals by giving them Apple Watches. Achieving certain goals, such as walking 10,000 steps in a day, enables members to “earn” their watch over time. The device will be integrated into UnitedHealthcare Motion, a national digital wellness program that provides eligible plan participants to activity trackers.

Similarly, this past August, the 60 million members of Blue365, the health and wellness program for Blue Cross and Blue Shield Association participants, will have access to Fitbit fitness trackers and gym memberships. Executives for the organization say the initiative will bring personalized health and well-being to the next level, enabling members to take steps to improve their health.

Finally, an article in Health Data Management discusses efforts by Louisville, Ky.-based Humana, one of the nation’s largest health insurance companies, to find ways to better use its data as the healthcare industry moves from fee-for-service to pay-for-performance models, says Roy Beveridge, MD, chief medical officer at Humana.

In the same way, providers are entering contracts that will increase their risk exposure, while incentivizing them to take more of a role in improving patients’ health.

More for you

Loading data for hdm_tax_topic #better-outcomes...