Authors: Shreekanta Kumar Sahu, Sr. Consultant, CitiusTech and Dr. Vishal Anand, Sr Business Healthcare Analyst, CitiusTech
Healthcare reimbursement is transitioning from traditional fee-for-service to value-based care models, making it easier for healthcare providers and health plans to work together holistically as payviders. However, to be successful, payvider operations require robust data integrations capable of analyzing the member experience.
Clinical data integration helps payviders generate a unified view of the data to understand population-level health and quantify risk. It also enables payviders to acquire, access, and share clinical data to improve member outcomes, reduce costs, and increase revenue. An associated member experience analytics framework should cover four essential aspects:
- Meaningfully engage. This step aims to create meaningful groups of members and prospects so that you can engage and personalize communications.
- Address care gaps. Payviders must first determine where gaps in care exist and then develop a plan to address them. For example, accessing clinical data using a SMART on FHIR API can help payviders identify gaps in care. FHIR standards-based resources can be used to send patient records from EHRs to payvider systems, fetch lists of open care gaps and impacted measures from the payer’s Gaps Rule engine, and display them through mobile apps.
- Drive consumer delight. By creating personalized engagement experiences based on members’ unique needs, payviders can exceed members’ expectations.
- Vertically integrate services. Payviders should seek to enable a seamless member experience across the payer-provider ecosystem. For example, using SMART on FHIR, payviders can build 360-degree views for members by allowing access to health data, including clinical, claims, formulary, and provider information. SMART on FHIR lets payviders provide a one-stop platform to access medical history, appointment schedules, pre-authorizations, claim history, vital dashboard, provider details/demographics, alerts and reminders, and wellness programs.
By using an analytics framework, payviders can enhance member risk identification and stratification, allowing them to personalize member management and engagement for more effective outcomes.