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.


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?

August 14, 2013

Care Management: Innovations and Trends - Empowered Member

Care Management programs are designed and executed to enhance care co-ordination, reduce cost while improving the quality of care. Howsoever well these programs are implemented; the changing market dynamics imposes new challenges, which needs continuous evaluation and innovative ways to increase the effectiveness of care management programs.  Let's explore some of the recent innovations and trends in care management.

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August 8, 2013

ACOs - Why they could fail?

Accountable Care Organizations (ACO) are healthcare organizations which are accountable for quality and cost of healthcare services. These are group of physicians, hospitals & other healthcare provider who provide coordinated high quality care to patients. ACOs would share financial responsibility with government and private healthcare insurers. Their payment models are quality-based, which differ from traditional quantity-based models. ACOs have the potential to reduce healthcare expenditure and improve quality of care. However, they face certain challenges which they need to overcome and avoid failure.

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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.

June 27, 2012

Meaningful Use -Springboard for Accountable Care Organization

In recent times, healthcare in United States has witnessed unparalleled revolution which is led by the government-driven multibillion dollar health reform initiatives. Most of these reforms intend to address the key menaces of US healthcare, which are spiraling healthcare costs, inconsistent healthcare quality and fragmented care delivery. Two such reforms that have grabbed nationwide attention are Meaningful Use and Accountable Care.
These reforms require the healthcare providers to work towards implementation of the electronic medical records and achieve benchmarks of meaningful use of technology, at the same time position themselves to join or form Accountable Care Organizations (ACO). In a shared accountability model like ACO, healthcare stakeholders are collectively responsible for entire continuum of care for beneficiaries with their reimbursements tied to the quality of care outcomes and cost savings. The successful conception and sustenance of this model calls for robust stakeholder collaborations, cross continuum care coordination, performance management and cost reduction strategies. The key to attain and sustain such a regional collaborative initiative would be a shared information infrastructure that presents accurate, complete and timely management and exchange of information.

Continue reading "Meaningful Use -Springboard for Accountable Care Organization" »

May 25, 2012

What should payors do to participate in the Accountable Care Organization model?

Though a lot of payers are still apprehensive about the success of the ACO model, a few payers including large national commercial plans and Blues have adopted the model and are moving ahead to capitalize on the opportunities. Adopting an ACO model is a transformational change for payers and will require substantial planning and preparation. This would involve changes across systems, people and processes.

April 20, 2012

ICD-10 and Meaningful Use - A Win-Win Transformation

Being governed by two separate federal directives, apparently "ICD-10" and "Meaningful use of EHR" are today touted as two distinct and possibly dissimilar goals, though they really are not. Both initiatives are an attempt to achieve two primary targets, i.e., 1) improved quality of care, and 2) reduced cost of care. It is just the means and approaches where they differ. Beyond the obvious congruence of objectives, there are similarities in implementation efforts also. Both "Meaningful use of EHR" and ICD-10 implementations impact not only the similar technology portfolio of the organization but also the same business process landscape and stakeholders, significantly. With understanding of such a common impact spectrum, when one is adopting EHRs for the purpose of meaningful usage, it makes absolute sense to add the ICD-10 logic in there at a small incremental cost rather than to leave the effort to a later day and incur additional, huge implementation bill.

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November 7, 2011

Six aspects to make US Healthcare Sustainable...A thought

Making healthcare affordable, accessible & accountable is not any unique initiatives to any health care system. The pivotal concern has been always to make the healthcare system sustainable. If I have correctly analyzed the prevalent facts & figures, I can well claim that the current US healthcare system is absolutely operating under an unsustainable bubble with a perfect mismatch of cost and quality giving rise to the increasing trend of inequity, inequality and inefficiency. Moreover, with the fast pace in healthcare market the future provisions are never an easy one to grasp. Changes are certain in medical technologies, management of chronic illness, reimbursement patterns, coverage policies & etc. In such a situation, if a healthcare system can't move towards a comprehensive system-wide reform or just aims (even with incremental changes) to address either financing or delivery system problems but not both, it is bound to be dysfunctional, lose its credibility and we will ever continue to waste billions of dollars and thousands of more lives every year. So, as an answer to this issue let me now weave the concept of a "True" sustainable healthcare system". Yes, I agree quality, cost, delivery & financing mechanisms are the four pillars, and still the open question is what is beyond these to reap the full impact in cost, affordability and accessibility and make health-care sustainable and for all including the most vulnerable ones.

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October 31, 2011

Scope for leveraging IT in establishing patient centred care in an ACO

Better care for individuals is one of the important goals for the ACOs in the Shared Savings Program as established by the Affordable Care Act. This highest-level goal also known as the three-part aim consists of the following:
•Better care for individuals - As described in the Institute of Medicine report, it has six dimensions of quality: Safety, effectiveness, patient-centeredness, timeliness, efficiency and equity
•Better health for populations with respect to educating beneficiaries about the upstream causes of ill health
•Lower the expenditures by eliminating waste and inefficiencies while not withholding any needed care that helps beneficiaries

Continue reading "Scope for leveraging IT in establishing patient centred care in an ACO" »

September 15, 2011

Promoting Accountability in ACOs - Part 3

My earlier blogs, part 1 and part 2 detailed the key concepts influencing the success of ACOs and the need of a change management strategy enforcing stakeholders acceptance of ACOs.

Continue reading "Promoting Accountability in ACOs - Part 3" »

August 18, 2011

Promoting accountability in ACO - A few insights (Part 2)

In the previous blog, we have introduced the two key concepts that are going to influence the success of an Accountable Care Organization (ACO):

• Establishing and adhering to a central Vision

• Establishing a standard clinical process and benchmark

In the previous blog, we had started the discussion on the first topic i.e. Adherence to a central vision, and here we will extend our discussion further on the same.  It has been observed that one of the primary reasons of higher cost of healthcare in the U.S. is the existence of the fragmented healthcare delivery organizations. Collaboration among the constituents has been suggested as one of the solutions if one wants to succeed as an ACO. But is it enough to put a right setup of people, process, technology and infrastructure? Most importantly, the ACO organization has to plan for an effective change management so that the gap between the current and future states in all the areas of healthcare continuum can be bridged.

Continue reading "Promoting accountability in ACO - A few insights (Part 2)" »

July 26, 2011

Promoting accountability in ACO - A few insights (Part 1)

In a successful Accountable Care Organization (ACO), establishing and sustaining the exchange of information flow among the individual constituents matter the most.

The term accountable care organization (ACO) was coined in the Medicare Shared Savings Program as part of the Patient Protection and Accountable Care Act of year 2010 (PPACA). The program, anchored by the Centers for Medicare & Medicaid Services (CMS), will share annual savings for a population of Medicare beneficiaries with a group of providers who form a provider organization that meets the defined criteria. Such groups are called accountable care organizations (ACOs).

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March 17, 2011

Video: State Exchanges & Individual Market- Part 1

March 16, 2011

Video: Health Benefit Exchange- Part1

November 30, 2010

HIEs as a vehicle for Meaningful Use

Meaningful use should not be seen just as installing a certified EHR and generating the required reports. Ability to exchange Health Information securely over the internet is one of the foundations that need to be in place for realizing the key benefits of improved quality of care and patient safety at lower cost. While most of the stage 1 criteria may not have a direct dependency on Health Information Exchanges (HIE), you can expect to see increased relevance of HIEs in near future, in the context of implementing some of the Meaningful Use (MU) requirements.

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June 7, 2010

Video: Strategies for ICD-10 Implementation

To Learn more about ICD-10 Implementation attend the Infosys' webinar 'Getting Ready for ICD-10'.

June 2, 2010

Video: Role of ICD-10 in Health Reform

To Learn more about ICD-10 Implementation attend the Infosys' webinar 'Getting Ready for ICD-10'.

August 3, 2009

Enterprise Data analytics: Breaking department silos

Organization departments have tendency work in silos and Healthcare Providers are no exception to this.  A leading insurance provider firm in USA was venturing into a new business in Canada and the IT team was busy working on the system requirements for the new business. The CIO sought this opportunity to make maximum out of the capital budget to invest in latest rules engine and custom application development. There was no consideration given to the revenue targets onto this new business or ROI on the IT system investment. Out of curiosity when I asked the CIO, his response was “ROI clouds the mind in any decision making. My priority is to ensure work for my team and have the systems in place to support business. It’s for business SMEs to extract maximum out of the system. This is what I call working in silos of departments by achieving individual department goals.

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May 27, 2009

Obama wants to reduce healthcare costs! But How?

After the Health Care Executive consortium meeting with Obama, the number 1 action is to reduce healthcare costs! But How?

Continue reading "Obama wants to reduce healthcare costs! But How?" »

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