Payers Beef Up Care Management Solutions

The payer care management solution market is undergoing a transformation, reflecting the industry’s drive toward value-based care, according to a new survey from the Framingham, Mass.-based IDC Health Insights. Providers would be wise take note of this development, as closer integration with health plans is expected in the new era of accountable care, which will rely heavily on core competencies more likely to have been mastered by payer organizations than by providers: population health and analytics.

In the IDC MarketScape report, “U.S. Care Management Solutions for Healthcare Payers 2012 Vendor Assessment—A Market in Transition to Health Engagement,” Janice Young, IDC Health Insights program director, Payer IT Services, says the most salient finding is that care management applications and solutions are in a moment of extraordinary transformation, reflecting the environment of healthcare reform, which requires large group plans to spend at least 85 percent of premium dollars on health care and quality improvement, while small group plans must spend at least 80 percent.

With newly architected solutions within the past 12–24 months, there will be much opportunity for payers to manage newly diagnosed patients, to identify their chronic patients early on, and recognize points of intervention, she adds. Another key will be to understand how to develop trust with patients to promote better health outcomes through consumer engagement tools, either through their physician or by other methods. “When a member is in a provider office, does the provider know what he needs to know about the consumer to treat them well?” asks Young. “In many cases, for better or for worse, the health plan has information about the consumer that could help manage that better. How do we structure that initiative for care and health and wellness?”

Providers Should Take Notice
Health IT leaders would be wise to keep an eye on technologies in the payer space, as many population health solutions are being created for payers that can be leveraged in the provider space as well. Linking these technologies in the two markets could help lay the foundation for the new risk-based structures required for accountable care.

“It’s worth providers really taking a close look at what’s going on in this marketplace, because most of these vendors are reaching to integrate with EHR and HIE initiatives that are being heavily invested in on the provider side,” says Young.

There are multiple opportunities of collaboration for providers and payers around quality-based programs or around specific types of health outcomes. “Many of the providers who are interested in ACOs models don’t necessarily have a lot of experience in population management and in the types of analytics and process management that health plans are very accustomed to,” she adds. “In some instances health plans and these technology vendors identified a role to provide these services and these technologies to ACOs to give them the platforms to manage these populations.”

Solutions are Changing
The need for better cost management, and better payer, provider, and consumer integration, amid the changing reimbursement environment are being reflected in the vendors’ emerging products. “The applications now are really creating a holistic 360-degree approach from a couple of different approaches, which is vastly beyond what the original and historical applications,” says Young.

Payers are ramping up their capabilities to examine the continuum of care including legacy care, case, and disease management initiatives, as well as to prevent hospitalizations and readmissions using communications management, integration, portal strategies, and real-time or near-real-time communications. Another focus has been an integration of analytics for both population identification and stratification, and outcomes analysis, using workflow technology to fire alerts against care gaps or best-practice health and care models.

“Most [vendors] are in the process, or have introduced capabilities or integration strategies or portal strategies to make processes of how the health plan is touching the individual consumer available to the consumer and the provider, and to a certain extent enable interactivity through those technologies, and it could be integration with an EHR, HIE, or direct information to a provider or consumer,” says Young.

Specific IT Requirements
Young says the most significant investment vendors will be making will be in beefing up portals for consumers and providers, and continuing to invest in partnerships with other analytics vendors.

Much will be done to better integrate provider, network, and payer information into business rules to identify referral sources or high-quality care opportunities, and send that information to providers within their current workflows. It’s been established that having separate physician portals for each health plan does not promote usage, so integrating health plan physician portals into EHRs will be another goal, says Young.

“The importance is the process integration with care and health management strategies with analytics and reimbursement and provider information,” says Young. “We see [the need for] analytics platforms that integrate the information that we know and link it to reimbursement and financial strategies.”

Vendors will be investing in new partnerships in the mobility market to provide health and wellness content to individuals based on their particular disease state. More investments will also be made in remote technologies to send health information like blood pressure readings, etc., to payers and providers. Payers will be spending capital on new tools to track and mange communications to consumers and providers based on data triggers to avoid redundancy.

“A lot of [the current market] is [focused on] shared information and collaboration in identifying what works best to engage consumers and providers with all the new technologies and capabilities,” says Young. “The difficulty is ‘let’s begin to shift the paradigm and use all this programmatic information to understand how to best engage consumers and position resources,’ which is not necessarily a technology problem.”