How Health Plans and Payers Can Improve Care Management in 2023

In 2023, data-driven care management will be crucial to achieving better outcomes for patients while reducing the total cost of care. There are many stakeholders involved in patient care management, but health plans and payers in the healthcare ecosystem occupy a unique position because they are responsible for managing resources of their members and have a more complete picture of all services a patient is receiving. As a result, health plans and payers must work towards improving health data exchange with providers for effective care collaboration. Health plans and payers in care management need access to high-quality, actionable, and timely data to coordinate care, manage utilization, and prevent gaps in care.

In this article, we will look at the role of payers in supporting better patient outcomes and how they can work towards a more effective data-driven care management strategy in 2023.

What is Care Management?

Before delving in, it’s important to clarify what is care management. The healthcare industry has been focused on the idea of achieving the quadruple aim of improving population health, reducing cost of care, creating a better patient experience, and improving provider wellbeing. Care management is an approach to enhancing care delivery with a team-based, patient-focused model of care. Care management involves identifying and defining patient populations that can benefit from preventive interventions and more targeted care coordination efforts to reduce health risks.

For example, a care management program might identify patients with chronic conditions to target outreach efforts and services aimed at helping manage the condition better to prevent emergency department (ED) utilization, inpatient hospital stays, and other acute, costly healthcare interventions.

The Role of Health Plans and Payers in Care Management

Health plans pay the cost of medical care, and payers process and pay provider claims for their members. The most common type of payers are health insurers and payviders, where patients can receive care from an organization that also covers the cost of care, like at the Department of Veterans Affairs in the U.S.

The payer’s role entails balancing cost and quality of care by managing the resources of each member’s healthcare plan to support the best health outcomes with the least amount spent to achieve that result. Typically, the focus is on preventing unnecessary or duplicative services, reducing ED utilization, and avoiding readmissions after a hospitalization. To help align cost with care outcomes of their members, payer care management programs tend to target areas like transition of care management, complex case management, chronic condition management, and lifestyle and prevention programs.

Interoperability and Preventing Gaps in Data

Health plans and payers in 2023 will need to work towards greater interoperability to prevent gaps in data that can lead to missed opportunities for coordinated care and patient engagement when the patient health data is incomplete. It is not enough to simply exchange data with providers: the exchange must be secure and bi-directional between payers and providers; it must be accurate and complete; and, most importantly, it must be timely and actionable.

Receiving or sharing data sourced from data that is fragmented, inaccurate, incomplete, or in an unusable format will not help payers or providers to manage care effectively. Instead, payers should seek out health information technology (IT) solutions that support real-time visibility into member activity throughout the care network to identify care gaps and ensure that case managers coordinate preventive care and proactive interventions. Enhanced interoperability for streamlined health data exchange will help health plans and payers better manage their members’ resources and offer effective engagement at the right time to reduce high ED utilization, support safe transitions in care, and improve member satisfaction.

Ways Payers Can Support Care Collaboration

Health plans and payers need to be able to engage providers to implement their care management strategies effectively. For example, payers can support care collaboration with providers by sharing data that identifies members in their care with a high-risk profile, which may include patients with complex or chronic conditions or those with behavioural health conditions. This helps providers to target patient populations who will benefit most from outreach, preventive interventions, or targeted care coordination efforts. Payers could also offer resources to support providers to implement quality improvement or utilization management activities like sharing effective care standards and best practices with providers or offering guidance on a quality improvement program targeting medication reconciliation after discharge.

All provider engagement efforts will depend on payers having a solid foundation of quality data and secure data exchange solutions to send and receive up-to-date, holistic patient health data, including clinical, demographic, social determinants of health (SDOH), and admission, discharge, transfer (ADT) data. Most importantly, having ADT alerts or data feeds sent directly within provider workflows will support more effective provider engagement than relying only on claims data alone. While claims data can be delayed by days, weeks, or even months, ADT alerts that notify a member’s care team when they are hospitalized, discharged, or transferred to a post-acute care provider can help fill gaps in health data critical to better care coordination and timely outreach to prevent readmissions and improve outcomes.

Health plans and payers that want to improve care management efforts will need to assess their current health IT solutions to determine if they have the tools and data capabilities necessary. Timely, actionable, and accurate data will mean the difference between a care management strategy that works in theory and one that works in practice.