At Infosys, our focus on Healthcare is aimed at radical progress in affordability, wellness, and patient-centricity. We believe technology is a catalyst for game-changing healthcare solutions. In this blog, we discuss challenges, ideas, innovations, and solutions for the healthcare economy.

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December 23, 2013

Take care along with coverage in the Health Insurance Exchanges

Affordable care is the goal for both enrollees and health plans participating in the exchanges. While exchanges will help health plans capture a larger market share, will they be able to reduce the overall healthcare costs?

Public exchanges bring in lots of tax benefits, premium subsidies, and models like defined contribution to provide low cost coverage to the uninsured population. However, with the provision to cover pre-existing conditions and increased competition, it will become more difficult for health plans to manage costs incurred to engage and service members.

Adverse selection, which increases the number of claims and associated costs, limits the ability of exchanges and participating health plans to contain the rising cost of care. Permanent Risk-Adjustments Mechanisms, introduced to address adverse selection, increase complexity and overheads for health plans and may not be very effective. Despite the costly and time consuming upgrades to core actuarial processes as advocated by the permanent risk adjustment mechanisms, health plans remain uncertain if the premiums setup will be sufficient to cover costs or not. This uncertainty increases premiums for specific plans. And, once the exchanges start supporting large employer groups, the cost control mechanisms would become more complex. Even if the risk adjustment mechanisms are made more effective to ensure stability of variable medical costs across uneven population, they will still remain a post-facto solution to curb costs. Is there a proactive solution then for cost containment?

Obama's reform vision of reduced costs and improved care requires a reformed care coordination process, harmonized with the health insurance exchanges. Providers, along with payers, need to take responsibility for cost containment. Care pricing models need to be reformed. Though exchanges have stringent plan certification process that focuses on provider cost and quality data, there is no mandate supporting the wellness programs and the value based care pricing models that are part of PCMH, ACO, and P4P programs. If preventive and proactive care initiatives such as these were associated with exchange plans then reform would encompass both cost and quality!

Provider payment reform and new reimbursement care delivery models need to be linked with exchange based plans. In addition, plan designs incorporating value based benefits can definitely incentivize patients to be compliant with the care process, enabling improved outcomes.

 Research suggests that one of the biggest lessons from Swiss insurance exchange is that care purchasing models are as important as network adequacy, cost, and quality data. The QHP approval process can take care of this. For high-risk populations attracted by the exchange, QHPs can be required to support wellness and care management programs (e.g., diet, life style and medication management) which would address the needs of the high risk population. At the same time, plan benefits can reward healthy behavior through seasonal initiatives or perks. Exchanges can encourage pricing negotiations between payers and providers and support innovative contracting models in QHPs.

ACOs and PCMH have already proven their models with millions of cost savings; why not apply them mandatorily in exchanges and make the exchanges efficient, sustainable, and capable of providing effective care along with coverage?

January 31, 2013

Applications of Big Data in Healthcare - Part 3

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.

May 25, 2012

Insurance Exchanges - What should you focus on?

With the healthcare reform, payers are now targeting the large base of uninsured and underinsured in the US market. Accountable care act mandates that every individual must be insured by 2014. This opportunity opens a significant market to the carriers.Some States initiated the steps towards setting up state exchanges. Some are opting for a Federal Exchange. Some states will also see setting up of private exchanges.


February 28, 2012

THE COMMON MAN'S EXCHANGE

The very mention of the word "Exchange" today, in the United States is associated with Health reform and the PPACA act which was implemented by President Obama in March 2010 and why not? It is probably one of the most discussed topics today.  The Exchange which is supposed to make insurance purchase a simple yet effective tool for the majority of uninsured population, has long been in controversy, sometimes due to actual reasons and concerns; like the cost of implementing an exchange or how to actually make the Exchange self-sufficient by 2015, both at the state level or sometimes only because of political conflict. The general public for a very long has been in a dilemma about what is in it, for them.

Continue reading "THE COMMON MAN'S EXCHANGE" »

February 22, 2012

Basic Health Program vs. Health Benefit Exchange

The Health Care Reform was launched with the idea of transforming the healthcare scenario in the entire United States, but how far will it actually serve the main purpose is the doubt I have in mind.

The main agenda of the much talked about Health Reform legislation is being able to make healthcare affordable for all the citizens of US as the act typically says "Affordable Care Act". But in the struggle for fulfilling the Reform's motive of care for all the policy makers are making provisions that in a way  contradict each other. The irony is that PPACA's act 1331 talks about establishing Basic Health Program, the implementation of which might lead to be a threat to the its own state established exchanges. BHP and Exchange can cut lines for each other. The ultimate decision with the BHP still awaits but it has the potential of affecting the successful running of Health Benefit Exchange, though both have their own pros and con's.

Continue reading "Basic Health Program vs. Health Benefit Exchange" »

March 17, 2011

Video: State Exchanges & Individual Market- Part 1

March 16, 2011

Video: Health Benefit Exchange- Part1

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