Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

Healthcare Payer, Provider Paradigm is Starting to Shift

By Ryan Mcaskill

IDC Health Insights research director Deanne Kasim talks about the the impact of evolving payment models.

- Earlier this week, this site covered a new report from IDC Health Insights that focuses on best practices for payer health management programs in the face of evolving payment models. The biggest takeaway from the study is that payers are rethinking traditional delivery models.

Fifty-one percent of responding payers said they have plans for new investments in care and disease management applications in 2014. This means that organizations have acknowledged a shift in operations is happening and are actively trying to get in front of it.

In an interview with, Deanne Kasim, IDC research director for Payer Health IT Strategies, spoke more in-depth about the study and what was discovered.

According to Kasim, this was not a survey as much as it was a fact finding mission. This was talking to a lot of health plans and vendors that serve their care management programs and finding out what are their biggest challenges, what is working and what hasn’t really worked the way they wanted it too.

“This was really what would you share with your peers and stand up at a conference room and say ‘this is what we’ve learned, this is what is working, these are best practices,’” Kasim said.

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Payer health management programs is a topic that a lot of payers health plans are struggling with right now particularly in a post health care reform environment. Kasim said there are two prongs to what’s going on. The first is the payer side which has traditionally been utilization management, case management, disease management, care management and then there is now with new reimbursement care models such as accountable care. Then you have the providers side doing a lot more of disease management and population health management, which has become an over reaching buzzword.

While at a conference earlier this week, Kasim said that one panelist stressed that you can’t be in health care right now and not be talking about population health management as a buzzword.

In the payment community, there are a lot of evolving practices as well as solution providers that are serving health plans with care and disease management solutions and are changing their product road maps. Kasim said that almost every single vendor she spoke with in the companion study is saying they do population health management (which really isn’t quite true) or they have a population health management approach.

“Where my constituents in the payer community are looking to go is, how can we take better care of our population and provide evidence based care that promotes wellness and cost efficiency and also what kind of systems do we need to enable,” Kasim said.

The information gathered in the report shows that overall better practices are coming from Medicaid plans, the Medicare advantage and some of the dual eligible pilot. The reason for that is these are smaller, better defined populations, as opposed to the commercial healthcare space where you have a variety of different populations both from big employers or the exchange of individual markets.

There is also more innovation in care assessment management and population health management from the government sponsored health plans. This is because these populations have a greater need for higher health care, more complicated and multiple diagnoses, particularly with medicare and there is a more compelling case to say “we have got to manage health and the costs of these populations because they really are the five percent that are driving 50 percent of the costs.”

Kasim mentioned that there were some surprises. Most noticeably is a changing of the old paradigm where payers have the money and the providers dictate the terms of the contract and reimbursement. Now providers are starting to ask about collaboration, sharing information and becoming business partners.

“I was really surprised that there are a lot of good things that plans are doing and they’re being rather innovative and thinking outside of the box and also the leaders in this area from what I have found are taking a different mindset,” Kasim said. “This has got to be a win-win and at the end of the day say its about treating the population and improving their care quality and their outcomes.”

Kasim wrapped up our conversation by saying the better practices she has spoken with are discussion some interesting discussions with the provider community about improving their star rating on medicare advantage plans or how to create better collaborative care and disease management. One of the challenges will be partnering across all levels of health care and ensure its not one stakeholder trying to drag everyone along.


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