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Cerner Impressions – Value Based Solutions: Payer/Provider Markets Getting Ever Blurrier

by Janice Young | July 27, 2016

fishyangWe all know that two of the principle new competencies for providers in the value based market is: 1. population health management and, 2. consumer engagement. Long the purview of the health plan market business and technology sector, one of the burning market questions is how the at-risk provider market will acquire these competencies.

Health plans and related health plan technology vendors have positioned both technologies and services for the at-risk market – and much of the market discussion earlier this year focused on health plan and health plan technology vendor market opportunities.

However, after attending Cerner’s population health management conference last week, it is worth re-emphasizing some very notable investments and successes in population health among the provider vendor community. Cerner’s strategy supports much of the population health business requirements of a provider organization including: risk identification, program enrollment, tracking, patient outreach, milestone and outcomes tracking and reporting.

Both vendor and attendee (providers, employers and some heath plans) conversations aligned with a model that shifts from a patient to a consumer focus and squarely placed the consumer (not the patient) at the center. Next up are social, financial and additional lifestyle metrics that make up the 70-80% of health status beyond direct clinical interventions.

Payers out there… Sound familiar?

As Cerner and others roll out these capabilities, it would be a sound payer strategy to take a look. Here’s why.

The provider solutions already have the clinical information and capabilities that have long been sought after by payers. As 10 years of as yet incomplete efforts among most of the payer care/population health management vendors would suggest, adding claims data to a strong clinical solution is easier than adding clinical information to a payer claims based solution.

And, it is of course the clinical information, combined with the claims/transaction data, that renders information useful in support of a population health management strategy.

Case in Point
Twice now I have been contacted by my health plan regarding prescription compliance. In the first case, I was encouraged to renew and continue taking a prescription that had been discontinued because of a potentially life threatening allergic reaction. In the second case, I was encouraged again to renew a prescription that had been discontinued because I no longer needed it. When I contacted the health plan representative, he admitted that they only used claims data and had no insight into any related clinical information. I asked to be taken off any further communications.

At the center of any population health initiative is the need for effective provider or consumer engagement, which requires credible, accurate, complete and timely information delivered at point of decision. Without that, both providers and consumers rapidly lose confidence and the ability to effect outcomes and improve health status is compromised

Health plans have used health plan care management vendors for years for their population management – TriZetto, ZeOmega, etc. Many health plans are looking at ways to leverage their traditional population health solutions to the ACO market. Cerner will ultimately compete directly with the traditional health plan population health/care management solutions. Cerner – and their competitors – have an advantage in that their solutions already integrate and use clinical information, something the payer care management/population health market is still trying to execute on.

Cerner, and others in the provider space, are more rapidly addressing this more robust clinical/claims information environment. Solutions are rapidly blurring across payer and provider care management/population health management solution domains,

While there is work to be done on all sides, health plans, particularly those pursuing joint venture strategies, should look carefully at solutions emerging from the largely unfamiliar provider market. Careful assessment, however, is required. Also expect further market consolidation via merger and acquisition (e.g. Evolent-Valence Health, Wellcentive-Philips, Phytel-IBM, etc.) among payer and provider vendor solutions.


One response to “Cerner Impressions – Value Based Solutions: Payer/Provider Markets Getting Ever Blurrier”

  1. Sue Ann says:

    “When I contacted the health plan representative, he admitted that they only used claims data and had no insight into any related clinical information.”

    We had a payer offer to incentivize us to complete immunizations — they pulled 69 patients and had about 300 immunization records. They had a 75% error rate, which we could document.

    I am still in a fight with BCBS of KS because their stupid claims system can’t pick up incentives they are supposed to be paying us for.

    I’m ok with incentives and HEDIS and quality measures. But I am damn tired of the inaccuracy of payer systems. If you measure us, at least get it MOSTLY right.

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