Advances in healthcare have turned many previously untreatable diseases into manageable conditions. Yet, prevention and early diagnosis and treatment remain the most effective means of staying healthy.. However, successful preventative interventions require an orchestrated collaboration between health payers and health providers who pledge to share information and work together toward a healthier population.
In a 2010 study, Health Reform, Prospering in A Post-Reform World, PricewaterhouseCoopers' Health Research Institute stresses that "health executives will need to reassess current strategies and find ways to work together." This belief still holds true, and as Ceci Connolly, the institute's managing director, highlights, "this convergence trend has been growing over the past years."
Traditionally, health payers and health providers have been seen as separate entities which have no reason to collaborate except when payments need to take place. In fact, as Graham Hughes, chief medical officer for the SAS Center for Health Analytics and Insights, notes, historically there's almost been tension between payers and providers. However, a new breed of collaborations are seeing the two entities work together in order to provide the best experience to their members and patients, mainly by avoiding unnecessary complications and embarking on early treatment. "We're starting to see the lines between the two becoming blurred," Hughes explains. Further, as Pat McCaffrey, TeleTech's senior vice president for healthcare and public sector, explains, technology is creating collaboration opportunities between payers and providers that previously didn't exist.
Tom Wicka, CEO of Novu, agrees, noting that the new collaborations are seeing payers and providers working together while keeping patients and members at the core and leveraging each other's insights to make sure patients and members are given the information and care that they need. In fact, as Connolly stresses, when separate entities engage in successful collaborative efforts, the result is often better quality health outcomes and prevention for patients and members.
Sharing data for success
The health sector is generating gargantuan amounts of data. At every interaction a patient has with his physician or other healthcare provider, a new set of information is generated, and with today's Electronic Health Records, saved. Additionally, every time a patient fills a prescription, that information is also recorded. Multiply this data by the number of people who have health insurance—more than 263 million in 2012 according to the U.S. Census—and we can start getting an idea of the huge amount of information that's being generated.
Yet, this data has traditionally been heavily siloed among the different entities that touch a patient. Payers, for example, tend to have claims data, allowing them to get a level of understanding of an individual patient's health profile, for example how often he visits a doctor and what interventions he required. Providers, on the other hand, have deeper information about that patient's interaction with them, for example his vitals and whether a particular condition is under control or might soon require further intervention. "It would be a wonderful thing if we can take the broad view and marry it with deep insight," stresses Hughes.
The benefits of better data management and sharing are mostly two-pronged. On an individual patient level, such initiatives will allow practitioners to better treat patients and make sure that nobody falls through the cracks. For example, a patient who's admitted to a hospital because of a cardiac episode will most likely need to alert his primary practitioner when he's discharged in order for care to be continuous. Yet, not every patient will immediately do so and this is one reason for costly hospital readmissions. On the other hand, if the health payer who receives the claim from the hospital is able to connect with the patient's primary physician, the latter can reach out to that patient and schedule an appointment to follow-up on any treatment within the community.
While the main aim of a collaborative effort is to have a positive impact on patients' health, Connolly also highlights the financial benefits. "When done well, you don't only improve health outcomes but can also reduce costs for everyone," she stresses. While analyzing the ROI of such collaborations can be problematic, Connolly notes that employers have seen the benefits of these efforts. "Employers believe there's a financial benefit," she says.
Overcoming the stumbling blocks
The different players in the health sector recognize that collaboration would lead to all-around benefits, but Connolly explains that this isn't a simple process. "If the different players don't share medical records and information so that everyone has a holistic view of patients in realtime, it can be a big problem," she notes. One main issue revolves around the availability of technology and the ability to share data. Hughes agrees, noting that data is many times not managed as effectively and efficiently as it should. "There's a lot of data that's messy and under-analyzed," he says.
Additionally, those spearheading collaboration efforts have also encountered cultural challenges. "Many companies have their own distinct culture and sometimes when you blend them together it can be difficult to get everyone with a shared sense of purpose," Connolly explains. This problem is especially prominent among practitioners who have historically been used to making more money when a patient needs treatment or is readmitted to a hospital within 30 days. She stresses the importance of really explaining and underlining that prevention and more emphasis on primary care is also financially feasible.
A third challenge that is also encountered by teams who are already engaging in collaborative efforts is reluctance from patients and members themselves to change their behavior, for example make lifestyle changes that reduce obesity and as a result also diminish the risk of certain diseases, like cardiovascular problems. Therefore, while providers and insurers might be sharing data that allows them to proactively reach out to an individual patient with the right information and following up to avoid him falling through the cracks between care, unless the patient is willing to collaborate the outreach won't be successful. "A barrier that must be overcome is the reluctance of members to engage with their health insurers at even the most basic level," McCaffrey explains. In fact, according to Forrester's report Mapping the U.S. Health Insurance Landscape From the Consumer's Perspective, 34 percent of insured online consumers had not interacted with their health payer at all during the past year, while 36 percent had done so only once or twice in that timeframe. "Enabling and encouraging member engagement based on value and insight is the key to the delivery of collaborative healthcare," McCaffrey stresses.
Cigna's Culture of Collaboration
Cigna is one health payer that is taking a collaborative approach seriously. According to Dr. Richard Salmon, the insurer's national medical executive for performance measurement and improvement, Cigna has been working with health providers—ranging from small practices to hospitals—and providing them with the necessary information to improve patients' lives and outcomes. The program, which started in 2008, takes a two-pronged approach, entailing both specific outreaches and population health improvement initiatives.
In the former, Salmon explains, Cigna works with individual patients' careers and equips them with the necessary information to proactively reach out to patients to cater for their health needs. "The care coordinator, embedded within the healthcare group, works with patients who are identified as most at risk and proactively reaches out to them to help them manage their healthcare," Salmon notes. For example, many times a patient who has just been discharged from hospital fails to visit his primary physician for a followup, leading to problems with continuity of care. "Many times people leave the hospital and go weeks before visiting their primary health physician," Salmon says. He explains that Cigna instead alerts the physician so that he can reach out to that individual patient and make sure he has all the care he needs, ensuring that no patient is falling through the cracks. Further, because Cigna rewards physicians for lower hospitalization rates, this approach becomes a financial incentive for doctors. "We have made this care improvement as something that's beneficial for health providers," Salmon explains.
The second approach provides doctors with more information about the needs of the population for which they're caring. For example, Salmon explains, many times doctors don't have any idea what cohort of their patients are visiting the emergency room. This data can be leveraged to make changes, for example extend their office hours so that patients can visit their physician rather than go to the ER.
The future of collaborative care
While payers and providers have started to embark on collaborations that can change patients' lives, the future should see more entities working together. During last months' Health Analytics Executive Conference, organized by SAS, Farzad Mostashari, visiting fellow at Brookings Institution, noted that patients themselves and their relatives can share important information about family history if they are made to understand the importance of sharing these insights and given the time to voice their views. Mostashari also stressed the importance of recruiting the help of relatives and even patients themselves to ensure prescribed medications are being taken religiously and any recommended lifestyle changes are made to help patients remain healthy.
Salmon agrees, noting that the future is likely to see more collaboration across different health-related entities. He notes that many employers are interested in increasing incentives for employees to stay healthy and already leveraging new provisions in the ACA for annual screenings and to reward for certain activities, for example fitness.
Connolly holds the same view and highlights the importance that other players, apart from insurers and healthcare providers, are involved in collaborative efforts to improve the population's healthcare. For example, pharmaceutical manufacturers can have an instrumental role in assisting practitioner teams to make sure that patients are following their drug regimen. Further, there could also be new roles for community members who can assist patients to remain healthy, for example teaching diabetes sufferers about new recipes that are good for their health.
Further, in today's technology driven world, collaboration can be much easier to achieve. Physicians are already connecting with each other to improve health outcomes. In the article The Healthcare Experience Revolution, 1to1 Media highlighted the initiative spearheaded by Boston Children's Hospital which created OPENPediatrics to connect healthcare providers around the world and give them access to information. "The global investment in healthcare-related technologies is huge and much of it is aimed at improving collaboration between healthcare payers, providers, and patients, enabling the delivery of care and a healthier population," notes McCaffrey. "It makes for an exciting and healthier future."
Similar information-sharing initiatives can bring together other players, allowing them to work collaboratively towards the same goal—healthier populations. "We are getting excited thinking about the available technology, for example remote monitoring and sensors that help you measure vital signs and transmit them electronically," Connolly concludes.