Plan, Doc Teamwork Seen as Key to Care

The Affordable Care Act (ACA) makes it inviting for health insurers and providers to merge their information, and that’s exactly what these stakeholders should do, says a study by the consulting company PricewaterhouseCoopers.

“Collaborating with providers allows insurers to build a deep longitudinal patient record, resulting in a comprehensive view into patient history without the typical limitations of time or care setting,” says the study “Advancing Healthcare Informatics: The Power of Partnerships.”

The data are gathered from reports by the Health Research Institute, including the report “Needles in a Haystack: Seeking Knowledge with Clinical Informatics,” which surveyed over 600 provider, health insurance, and pharmaceutical executives. In addition, “14 in-depth interviews with thought leaders and executives in health plans and industry organizations” were conducted.

The study argues that “the role of the insurer is beginning to shift from transactional processor to ... change agent, putting technology capabilities and data sources to work in partnership with other stakeholders.”

The ACA “and the emergence of new delivery and payment methods such as accountable care organizations” mean that the system “needs data capabilities and processes that work in an outcomes-based world,” the study says.

The industry is moving away from individual care that uses data from claims to “personalized care, which aims to integrate the member’s unique clinical, social, genetic, and environmental information to maximize overall health.” However, the interlocking system needed to pull this off has yet to be assembled.

The study states that both insurers and providers can contribute to the process. “Insurers bring strong actuarial skills to the table that can help providers calculate the cost of current and future business risk. They can also provide physicians with financial strategies for managing costs and metrics for driving quality improvements on a large scale.”

Meanwhile, providers are starting to realize that “insurers may have the manpower and capabilities to engage thousands of consumers every day, vastly expanding opportunities for clinicians to communicate with patients.”

Insurers need providers because insurers “face an enormous challenge in establishing themselves as their members’ reliable go-to source of information. When confronting a medical problem, consumers go to many other sources before they look at their own health plan’s Web site.”