Posted: 23 Apr. 2019 5 min. read

Can better data coordination help connect health plans to the future?

By Sarah Thomas, managing director, Deloitte Center for Health Solutions, Deloitte Services LP

Health plans collect mountains of data that they use to manage risk and improve care management and population health. However, despite the potential value of this information, these functions tend to be separate and uncoordinated. Can health plans do a better job managing the data needed to support the upcoming changes to Medicare Advantage (MA) and Medicare Part D? Absolutely! Health plans could—and some already do—use data from diagnoses, utilization, and quality gaps to identify high-risk members and to determine methods of care, which could help improve population health. This could also help streamline reporting.

Recent announcements from the US Centers for Medicare and Medicaid Services (CMS) reminded me of a new and relevant project. The emphasis is on the policies underlying these very activities, which not only affect payment, but also help improve patient health and overall spending. Health plans that invest in collecting, managing, and using patient data to improve outcomes and costs in MA and Part D will likely have an edge over others. Such investments could also help reduce the cost of compliance and highlight new ways that data can be used. Getting a better handle on data could also help health plans move beneficiaries toward a future of health that emphasizes prevention and well-being.

On April 5, CMS issued a Final Call Letter, which includes changes to the risk-adjustment and quality rating/incentive programs (see the April 9, 2019 Health Care Current). These programs have become critical features in Medicare. The agency also wants health plans to more effectively manage the outcomes and risk among Medicare beneficiaries who have chronic health conditions or addiction issues. The final rule also lets MA plans expand telehealth services beginning on January 1. It is clear from this guidance—and from the legislation preceding it—that regulators and lawmakers want health plans to play a role in improving population health.

Health plans aren’t quite there

It appears that many health plans might still have a way to go when it comes to coordinating their use of data, according to recent conversations with health plan executives and vendors. Here’s what they’ve told us:

The use of data is often duplicative and not well-aligned. None of the executives we interviewed said they have fully integrated the data, people, technology, and processes that are needed to form an enterprise-wide view. While the health plan executives acknowledged data collection/dissemination processes could be streamlined, they admitted those functions typically aren’t coordinated.

Risk adjustment, quality, and care management functions are partially or totally segregated. Most of the health plan executives said their organizations intend to integrate and align risk adjustment and quality functions. These plans tend to either be in early stages, or the strategies are still being mapped out. Some health plans are establishing centers of excellence, while others are creating senior-level positions that focus on risk adjustment and Star ratings. Several health plan executives said they are moving quality program management from the chief medical officer to the finance or government departments.

Many health plans are waiting to invest in emerging technologies. Most health plan executives we talked to see potential in artificial intelligence (AI), robotic process automation, cognitive computing, and other emerging technologies. However, some of them want to capitalize on the technologies they already have in place before investing in something new.

Improving efficiencies in the short term

How can health plans take steps toward the future—a world where data are seamlessly coordinated and continually updated? They can start by organizing more efficiently around the systems they already have in place. Health plans should consider applying an enterprise-wide approach to understanding where the data are, overhauling existing processes to optimize the flow of data, and adopting emerging technologies to further enhance their use of data.

How about the long-term?

We are all excited about our vision of the future of health and what it might mean for health plans and other industry stakeholders. Looking forward to 2040, we envision a future of health where actionable health insights are driven by radically interoperable data and smart AI. The use of optimized data can help health plans identify illness early and intervene much more quickly…maybe well before any symptoms appear. Health will be focused more on well-being than on treatment.

In the future of health, the always-on, sensor-driven environment will generate massive amounts of data—data that are continuously gathered and stored by multiple owners and selectively shared and used to improve health. The data will come from traditional players (health plans, providers, government regulators) and non-traditional players (digital giants, retailers, and consumers). This kind of radical interoperability will enable seamless integration of multiple, disparate data sources and apply advanced analytics to create real-time insights that will improve the patient experience and drive the delivery of always-on care.

Risk adjustment, quality measurement, and population health/care management are three important activities for health plans. Here’s where we see them 20 years from now:

  • Risk adjustment: By 2040, the need for risk adjustment—and the teams, processes, and technologies to support it—could be substantially minimized as illnesses are identified and addressed at the earliest stages. Risk-adjustment models that are based on a complete health picture of the patient—rather than on a specific condition—could be far more accurate and dependable.
  • Quality measurement: In the future, quality measurement could shift away from tracking what we can measure and move toward tracking only what we want to measure. For most patients, that means achieving goals—whether it is to improve function, restore function prior to an injury, reaching personal health goals, or something else. Under this vision, the industry will revolve around patients and their needs.
  • Population health/care management: The programs that we know today will be aimed at preventing disease, rather than managing care once an illness becomes apparent. We envision a shift to business models that are built around sustaining well-being and enabled by predictive technologies and comprehensive data on each patient.

This is all exciting to think about! Although 2040 seems a long way in the future, I think it is helpful for health plans—and regulators—to think forward to determine how they can help evolve care management, accountability, and incentives as technology and the availability of data and insights accelerate.


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Sarah Thomas

Sarah Thomas

Managing Director | Center for Health Solutions

Sarah is the managing director of the Center for Health Solutions, part of Deloitte LLP’s Life Sciences & Health Care practice. As the leader of the Center, she drives the research agenda to inform stakeholders across the health care landscape about key trends and issues facing the industry. Sarah has more than 13 years of government experience and has deep experience in public policy, with a focus on Medicare payment policy.