Payers – What They Are Good At, And What They Need Help With
In our house when we paint a room, my husband does the big rolling of the walls or ceiling, I do the cut-in work. I am good at prepping the room, taping all the trim and deliberately painting the corners. However, I am thrifty and constantly concerned that we won’t have enough paint to finish a room. My husband isn’t afraid to use enough paint and is extremely efficient at painting a wall in a single even coat. As a result, I don’t do the big rolling and he doesn’t do the cutting in. It took us awhile to figure this out, and a few rooms had to be repainted while we were figuring it out. Now we know what we are good at, and what we need help with.
Payers roles are changing. Payers were previously focused on risk assessment, setting and collecting premiums, analyzing claims and making payments – all while optimizing revenues. Payers are pretty good at selling to employers, figuring out the cost/benefit ratio from an employers perspective and ensuring a good, profitable product. With the advent of the Affordable Healthcare Act along with a much more transient insured population, payers now must focus more on the individual insured and be able to communicate with the individuals in a more nimble manner than in the past.
Individual members will shop for insurance based on consumer feedback and price. They are interested in ease of enrollment and the ability to submit and substantiate claims quickly and intuitively. Payers are discovering that they need to help manage population health at a individual member level. And population health management requires less of a business-data analytics approach and more social media and gaming-style logic to understand patients. In this way, payers can help develop interventions to sustain behavioral changes for better health.
When designing such analytics, payers should consider the following key design steps:
- Extend data warehouses to an analytics appliance
- Invest in a big data platform to absorb patients’ social data
- Build predictive analytics for patient behavior
- Bridge collaborative and behavioral analytics with claims to build revenue and profitability
Due to payers’ mature predictive analytics competencies, they will have a much easier time in the next generation of population behavior compared to their provider counterparts. As clinical content is often unstructured compared to the claims data, payers need to pay extra attention to context and semantics when deciphering clinical content submitted by providers. Payers can use help from vendors that can help them understand unstructured data, individual members. They can then use that data to create fantastic predictive analytic solutions.