Health insurance and Accountable Care Organizations (ACOs) are faced with constant challenges due to a rapidly evolving health care landscape fueled by change from compliance initiatives, health reform and an unstable economic environment. To tackle these challenges, health plans and ACOs need to develop go-to-market strategies and analytics solutions that define the organization’s future position and answer critical questions surrounding growth, profitability and sustainability. The ultimate success of these organizations will be determined by its ability to:
- Predict shifts in their customer-base
- Manage the cost of care
- Collaborate more effectively with providers
- Increase NCQA and HEDIS quality scores and Medicare Five-Star rating
Access to actionable lab data plays a significant role in the success.
Health plans utilize care management programs that typically implement a variety of interventions tailored to needs of specific groups of affected individuals. A model that identifies those individuals who have high risk of complications has the greatest potential to impact outcomes and lower healthcare cost. Complete and real time lab results can help health plans model individuals who have high risk of complications, greatest potential to impact outcomes, and lower healthcare cost.
It is necessary for health plans to access to lab results to help them better determine the effectiveness of care management programs. Some of the challenges and opportunities regarding lab data include:
- Health Plans and ACOs typically experience difficulty receiving clinical data from labs.
- Clinical data can have a significant impact on a health plan’s Medicare Five Star Rating, NCQA and HEDIS quality scores.
- Health plans and ACOs seek laboratory data to reduce instances of drug contraindications, generate clinical alerts, and populate personal health records.
- Lab results can demonstrate the efficacy of care management programs.
- Ability to provide clinical data can be an important factor for a lab to achieve in-network status with a health plan or ACO.
- Health Plans and ACOs share in a unique position to help a lab understand leakage (testing performed by out-of-network lab).
Health plans and ACOs need a true interoperability solution for lab and clinical data which can better enable their organizations to manage and lead in the coordination of individual care, support shared savings models, and deliver measurable and actionable outcomes that help health plans drive down the cost of care and ultimately improve population health.
Brian Muck is the SVP of Sales & Marketing for Halfpenny Technologies
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