Architectural Strategy for Payers: Patient of One

Transcription

1 Architectural Strategy for Payers: Patient of One Jeffrey D. Rivkin M.Sc, CPEHR, CHRS, PAHM, CBIP, CDP, CCP Research Director IDC Health Insights Payer IT Strategies

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3 Situation Provider Network of One Medical Profile of One Bill payment has been the focus of data sharing between medical, dental and vision facilities and insurance, not the patient Personalization is becoming expected by consumers There are four islands of consumer technology, data and strategy in payers: Loyalty or Provider information is disjointed and administered all over the Retention Prospect Target of One payer organization, yet consumers demand updated, accurate information for their entire patient experience- medical, dental and vision. Clinical patient data is evolving in the medical management or Administrative Profile and care coordination arm as utilization, care, and disease Subscription Events of One management migrates to universal care coordination Administrative Member profile and event data is held in multiple enrollment, claims and/or payment systems Marketing and Sales are awakening to consumer acquisition, win-back and speed-to-market paradigms that have been standard in other industries, but are new to payers. Insurance is migrating to be a collaborative partner in care. IDC Visit us at IDC.com and follow us on 3

4 Provider Information Provider Network of One Provider information can be found in Provider portals Credentialing systems Directory systems Provider incentive systems RX, Dental, and Vision carve-out systems Hospital ADT capture systems EDI/EFT systems Provider contract systems and HEDIS/ quality monitoring systems. Challenges are increasing as consumers demand more than provider network definition and demographics. Customers want to extend their networks to include their spa, grocery store, wellness provider, nutritionist and whatever or whomever their perceived network-of-one is. Most payers are not prepared to manage this type of network-of-one paradigm IDC Visit us at IDC.com and follow us on 4

5 Clinical Patient Data Medical Profile of One Clinical patient data can be found in: electronic health record systems authorization systems, referral systems multiple claim systems connected health partnerships wellness systems with product "points clinical milestone (e.g. obesity, smoking) accumulators illness burden stratification systems dental tooth charts carve-out systems for vision and dental Future use of remote monitoring devices, biometric sensors (now becoming commodities), pharmacy dispensing, and other connected health partnerships will further increase the complexity of managing clinical data. IDC Visit us at IDC.com and follow us on 5

6 Administrative member profile data Administrative Profile and Subscription Events of One Administrative member event data capture Administrative member profile data can be found in enrollment systems, customer service systems, enterprise master patient locator (EMPI) systems, member portals, claims systems, and EFT systems. Challenges are increasing because these systems were not designed for flexible terms (name your own price, value-based reimbursement), and reactive processing (e.g. vanishing/ behavior actively reducing deductibles). Isolated from other health plan systems Administrative Member event capture can be found in chat systems, claims systems, enrollment systems, EOB systems, corporate communication systems, deductible accumulators, product "points" milestone accumulators (e.g. wellness checkup, PCP selection, self-assessment), and RX, vison and dental carve-out accumulators. Challenges are increasing as combined accumulators, discounts for triggering events, and event-driven products become the rule, not just the trendy exception. IDC Visit us at IDC.com and follow us on 6

7 Marketing and Sales information Loyalty or Retention Prospect Target of One Consumer data relevant to Marketing and Sales can be found in campaign systems, purchased (demographic, lifestyle, credit) data, and extracts of member data warehouses. Warehousing was purported to get all industries there. It came close with the technology (relational, star) available Payers learned a lot, but didn t realize at that time the level of personalization that the consumer would expect. IDC Visit us at IDC.com and follow us on 7

8 AYER FOCUS FOR STRATEGY AND TECHNOLOGY- DOES THIS INITIATIVE DRIVE TO PATIENT-OF-ONE? IDC Visit us at IDC.com and follow us on 8

9 PAYER FOCUS FOR STRATEGY AND TECHNOLOGY- DOES THIS INITIATIVE DRIVE TO PATIENT-OF-ONE? Provider network of one Prospect target of one Patient of One Clinical profile of one Administrative profile of one IDC Visit us at IDC.com and follow us on 9

10 PAYER FOCUS FOR STRATEGY AND TECHNOLOGY- DOES THIS INITIATIVE DRIVE TO PATIENT-OF-ONE? Attributed primary physician Nutritionist Pharmacist Specialty physician Hospital Nurse practitioner/ Physician assistant Consumer / prospect segmentation Lifestyle demographics Wellness coach Counselor Health spa Condition Provider network of one Clinical profile of one Patient of one Prospect target of one Administrative profile of one Consumerspecific benefit plan offerings Sales/ Marketing encounter Customer service encounter Illness burden score Medical event Financial event Enrolled benefit plan Care plan Episode Case Patient/ network Encounter Premium payment Appeal Claim Subsidy receipt and reconcile IDC Visit us at IDC.com and follow us on 10

11 What do I do? Essential Guidance Prospect Target-of-One o Assume consumers will be switching out and back; eliminate "renewal" mindset o Separate Acquisition, Loyalty, and "Win-back" campaigns o Personalize products offerings Provider Network-of-One o Assume any consumer services source can be a "provider" o Sponsor Virtual Care Customer/Member Profile-of-One o Consider lifetime value and illness burden, and manage your customer relationships accordingly o Value a customer over a lifetime, not just per subscription (year) o Consider medical, dental, vision, and social determinants Medical-Profile-of-One o Understand the evolving standards of medical data capture, storage, and exchange o Contrast the data categories in medical records, dental records, and vision records to how a payer looks at patient. IDC Visit us at IDC.com and follow us on 11

12 Essential Guidance with Technology Provider Network of One Medical Profile of One Assume anyone can be a provider Sponsor virtual care Build/Buy a Provider System of Record Understand HL7, CCD, CCA, FHIR Contrast data content for members and patients Retain all data Use Predictive analytics Use derived segmentations Patient-of- One Eliminate assumed renewals culture Separate campaign types Personalize product offerings Use Product Configuration Software Use LIFEID software Use CRM for Sales and Marketing Use lifetime value, illness burden derivations Take multi-year view Bundle enrollment into CRM suite Integrate Customer Service into CRM across LOB Loyalty or Retention Prospect Target of One Administrative Profile and Subscription Events of One IDC Visit us at IDC.com and follow us on 12

13 Key Takeaways Payers have disconnected from customers over time, separating the person from the transactional unit processed by the company. Payers separated the patient from his/her medical service via a claim, the subscriber from his/her care requirements via a generic one-size-fits-most plan from an employer, the patient from his/her diverse provider desires via a specified network, and the customer services desired via a call center script or Web site. Bill payment focus, mass marketing, internal departmental applications, and claims emphasis are now replaced with data sharing, consumer personalization, enterprise focus, and a partner-in-care mission. Successful payers will take holistic consumer approaches around the patient-of-one philosophy that unifies their prospect, network, administrative, and clinical strategies and technologies. IDC Visit us at IDC.com and follow us on 13

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15 Contact Information Jeff Rivkin Research Director IDC Health Insights Payer IT Strategies Join me and your peers and the conversations in our IDC Health Insights Community The Business of Healthcare + Technology Follow me on: Follow IDC on: /jrivkin1 IDCResearch IDC Visit us at IDC.com and follow us on 15

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