Healthcare Economy

Social Media has brought a wide range of opportunities to the Insurance industry for reaching out to consumers with a view to improve performance in the areas of Marketing, Sales, Knowledge Dissemination, and Recruitment. The traditional ways of conducting business in these areas are now going to be redefined in the era of social media. However, leveraging social media in the business operations requires careful planning and execution as there are quite a few constraints to be overcome.

In this blog and in the next set of blogs, I am going to discuss the challenges and constraints faced by the healthcare payors and the various ways of overcoming those in order to stay competitive in the market.

Social media is gaining the attention of the healthcare payors, insurance agents, brokers, healthcare providers due to its wider accessibility to the healthcare consumers across the world. The social media is one of the fastest means to reach out to consumers and create brand image. This is also one of surest ways to engage the existing members/policyholders and retain them. However, the insurance industry especially the healthcare industry has been a highly regulated industry. Even though more and more payors are adopting social media, still majority of them have been very cautious in their adoption.

I think it is a good way to start the discussion by focusing on the key areas where there is an increasing demand for social media in the health insurance industry.
• Communication and stakeholder engagement : Payor organizations leverage social media to achieve effective communication to its   members, collection of feedback from members , and better collaboration between payors and the members.
• Creating public awareness on the social initiatives of the Organization : To disseminate  industry related  information to its members and educate them on various government regulations
             o New laws enacted by the Government (such as Health care reform laws in the U.S.)
             o Government regulations (e.g HIPAA, CMS regulations)
             o Fundraising event organised by the organization for a social cause
             o Organizational news (such as such as new program launches and enhancements)
• Brand and Image building
• Creating various social forums where public can participate and give feedback
• Social Media Campaign - In the last few years, Centers for Disease Control and Prevention (CDC) in the  U.S.  has developed a number of integrated social media campaigns, including campaigns for the novel H1N1 flu event, the Salmonella Typhimurium outbreak associated with peanut butter and peanut-containing products , as well as seasonal influenza vaccination campaigns. Each campaign integrates innovative social media products with research-driven strategies to ensure that CDC protects and promotes the health of diverse audiences.

With the introduction of health insurance exchanges, guaranteed issue will bring 35 million (approx.) new customers into the U.S. healthcare marketplace by 2016. It is highly likely most of them will have higher than average medical costs, thereby raising premiums for everyone in the insurance pool.  The onus will be on the individual members to take the ownership of their own healthcare expenditure and support the payors in controlling the rising premium. 
We will focus in this blog how the payors can involve the members more by introducing member centric programs in the plan design and how big data will be leveraged to provide the required intelligence to the payors to achieve it.

The member wellness and preventive care program is already a key focus area for the payors.  However, these programs need to be customized for the specific needs of the members rather than being offered as a generic program. In my point of view, following could be reasons why this is not very effective yet.
• The wellness and preventive programs are generic which might not suit to the needs of the members.
• The members who need specific programs often do not find those being offered by the payors or do not get the required incentives or mandates from the payors for adequate usage.
• The patients are often not knowledgeable on the needs of the wellness program so as to take it seriously.

If we analyze the problem critically, it can very well be inferred that payors usually lack the intelligence (information perspective) which will enable them to customize the wellness program for a member. With the help of Big Data analytics, the data, already available in abundance from multiple sources, can be analyzed to get the information on the risk exposure of an individual to certain diseases (current or in future). Utilizing this information, the payors can come up with the following.
• Design the wellness and preventive programs for a member.
• Come up with the incentive or penalty structure to encourage the member to take up these programs seriously.
• Continually educate members on the diseases and on the availability of the required preventive programs.

ICD-10 is an opportunity for healthcare providers to reinvent and optimize revenue management. In the short term, it raises concerns about adverse impact on revenue cycles, given the current alignment of revenues with ICD-9 and the magnitude of the changeover. Thus, health care analysts from managed care services, revenue cycle management, clinical managers and financial reporting areas need to understand the financial impact of ICD10 transition across all business dimensions, not just those directly impacted. Providers will need to ensure that reimbursements based on the new ICD-10 codes are within acceptable variances and changes to payer contracts are proposed on a revenue-neutral basis.

Continue reading "ICD-10 financial neutrality assessment helps mitigate revenue cycle risks" »

These days, lifestyle based health ailments are becoming a major cause of concern. Today we have many wellness mobile applications available in the market which provide fitness and wellness recommendations for the user. However, these applications follow a generic approach in the wellness recommendation they suggest based on a limited set of parameters like age, gender and weight. They do not take into account the food, lifestyle and health status of the user, thereby not providing a personalized approach to wellness and fitness.

Continue reading "Role of Personalized Smart Phone Devices in Preventive Health Care" »

The healthcare fraud is one of the dominant factors behind the rising cost of healthcare globally. The majority of the frauds are usually associated with upcoding of services and items, billing for services not rendered, unbundling, duplicate claims.  The providers tend to use incorrect procedure codes in the claim form they submit to payor for which claim payment is higher.
 
The major challenge the payors face is how to develop the required intelligence to detect the fraudulent claims during claims processing and avoid reimbursing higher amount to the providers.

The payors can leverage the already available patient data points, structured as well as unstructured, and feed them to Big Data algorithms to identify the fraudulent claims. Some of the data points which payors need to consider for a patient include

• Patient demographic details and susceptibility to any specific disease
• Patient disease history
• Past history of the medical procedures undergone for the disease
• Preventive care records

To cite an example if the claim has been submitted for fracture in the knee, the payor needs to know the requirement of blood sugar test which is administered along with other procedures. This could be a redundant test as the patient is not diabetic. By analyzing the unstructured data available through Big Data algorithms, the payors can acquire the additional intelligence to detect the fraudulent claims.

Healthcare provider organizations should place alleviation of financial impacts at the core of their ICD-10 strategy to better address other key aspects such as reimbursement variations, staffing requirements, and vendor management. It is essential to formulate a revenue focused strategy in order to overcome the cost barriers.

As patient care is the utmost priority for the providers, they need to have financial viability to provide it and thus understanding the coded data and how it relates to financial data is essential. Providers will also need to analyze their case mix in order to monitor the diversity, clinical complexity and resources needed for their patients. Knowing this will help them to focus the limited budgetary resources. Moreover, the shift towards 'value-based purchasing' forces providers to frame strategies to strike a balance between cost and quality of care by prudently manage their budgets. 

Continue reading "Analytics tools - a solution for providers to assess the financial impacts of ICD-10 migration" »

With the advent of Health insurance exchanges as part of healthcare reform initiatives in the United States, the insurers/payors will have to sell a subset of their plans through the state-level public exchanges. The members will have the facility to compare the plans sold by different insurers before taking the final purchase decision. The payors have come up with private insurance exchanges where they are selling health plans to typically large employers.

The payors will face several challenges in order to maximize their sales through exchanges.

• How to capture the healthcare needs of the members or employees which can be incorporated in the health plans sold through the exchanges
• How to accurately calculate the health insurance premiums for the plans sold in exchanges so that it will be lucrative to the members without compromising the profitability
• What are the various wellness programs that can be offered as part of the benefits in plans sold through the exchanges
• The employers and the members alike will look forward to health insurance exchanges for reducing costs and getting adequate healthcare choices

The solutions to above challenges are dependent on how accurately the needs, interests of members/employees are predicted. The health analytics will play a key role in helping payors achieve the accuracy.
There are a lot of discussion forums, feedbacks on the performances of the health plans offered by the payors which are available in public sites. This information is huge in size and can be systematically analyzed to understand the member mindset as far as healthcare spending is concerned. Big Data algorithms will find a useful application here in order to achieve this accurately and provide the additional intelligence to the payors.

Big data can be leveraged for unstructured data analysis in the following areas.

• Members' buying and spending patterns in Health insurance
• Members' spending and participation patterns in wellness programs
• Health habits of different groups of member populations
• Healthcare choices availed by the employers (Large / Small Groups)
• Further enhancing exchanges with additional facilities so that more healthcare choices can be provided with less cost.

New Year, new predictions, new trends, and new to-do lists. 2013 will bring many new opportunities for your practice, including the chance to re-evaluate and prioritize ICD-10 planning and preparation.

Continue reading "2013 ICD-10 Project Planning - Using Dual Coding" »

Social networking and social media is an integral part of our lives in today's digital age. Studies by Nielsen show that 65% of adult American's have social networking profile and spend about 23% of their time spent on the internet on social networking sites. While online these individual disclose their views, opinions and a lot of useful information via Facebook posts, tweets on twitter or by generally liking and disliking other people's feeds. This data is used by large corporation from Service and Manufacturing sectors to analyze their current business strategies and to enhance their products and services and reach out to a wider audience. Healthcare sector has huge potential to utilize the data from these social networking sites to increase the level and quality of care management.

Continue reading "Social Network Integration with Care Management" »

The transition to ICD-10 is inevitable, impactful and invasive. But before healthcare providers start fretting about this complex migration and its extensive requirements, it is vital they realize that its benefits are numerous - including lower costs, enriched care delivery, fewer errors, and greater efficiencies.

Healthcare providers must leverage this compliance regimen as an opportunity and transform processes and technology to maximize performance and returns. They must act fast, analyze the impact, and adopt a holistic approach that embraces business and technology. Read our view point on what healthcare providers should know to ensure a smooth transition to ICD-10; the most effective approach for the migration and last but not the least about the best implementation partner.

Read the complete article here