Healthcare Payer Insights
Three Themes Shaping the Industry… and the Discussions at RISE Nashville
March 17, 2019
As a kickoff to spring, the healthcare conference circuit makes its next stop in Nashville this week to discuss and address the evolving nature of the industry’s ultimate goal; improving the delivery of value-based care. Conversation at the 13thAnnual RISE Nashville Summit will focus on some of healthcare’s most pressing and disruptive themes, including risk and quality, care management and delivery, data analytics, and compliance. While there will be so much to discuss in Nashville, we anticipate many of the conversations will include the following:
Theme 1: New Models of Care and New Approaches to Risk Sharing
With the industry’s crosshairs aimed squarely on driving increased quality and lower cost through value-based programs, we are in the midst of a revolution in the way patients are managed and care is being delivered. Early data suggests that this shift to value is happening rapidly and successfully, with a 2018 Change Healthcare survey showing nearly 2/3 of reimbursement went through a value-based model last year, resulting in an average cost savings of ~6%. Often referred to as “new models of care”, these value-based innovations are all trying to address the same questions – how can better clinical care be delivered in lower cost settings, and how can we align the goals and incentives of all constituents? In response, we have observed an increase in vertical integration – payers acquiring providers – as well as the emergence of disruptive vendors creating care models that shift risk to providers and share the risk (and the value) in delivering better quality care. Whether it is delivering higher acuity care in the home, leveraging new technology that coordinates previously fragmented care teams around a member-centric model, or developing analytics that identify and route care to the appropriate setting, these new models of care are forcing the alignment of all healthcare constituents. These changes introduce a need for technology and solutions that can ‘retool’ the industry’s pipes and enable new ways to manage, track, and align metrics and incentives to address the demands of these new care models.
Theme 2: Identifying and Addressing Social Determinants of Health
“Social Determinants of Health (SDoH)” has certainly been a term of note in recent months, and for good reason: according to California Health Care Foundation, nearly 60% of health outcomes are ultimately determined by non-clinical social factors. These factors, including personal finances, nutrition, living conditions, and access to transportation have all been shown to dramatically affect the risk of key cost drivers such as hospital readmissions and emergency room visits. Many in the industry have determined that it is impossible to effectively control the costs of our most at-risk populations without first addressing these core social determinants. Validating this line of reasoning, CMS recently approved the inclusion of non-skilled care as a supplemental benefit for patients with Medicare Advantage, allowing plans to begin addressing many of these social determinants. Because of this, potential solutions to these SDoH are finally gaining access to reasonable funding and reimbursement models, which is sparking innovation and disruption. As we will touch on more in a moment, a key barrier to successfully managing these risks is developing access to data that can help predict SDoH — like how often an elderly individual leaves the home, or how long someone’s commute is to visit their PCP. Developing technology and services that will allow for effective SDoH interventions presents a significant opportunity to drive cost savings across the population. With hundreds of billions of dollars of potential savings estimated among Medicare, Medicaid, and dual-eligible populations, we are in the early stages of developing modern solutions to address these critical health determinants.
Theme 3: Moving from Disparate Data to Actionable Insights
On the back of regulatory drivers, increasing digital adoption, and general innovation, analytical capabilities across the healthcare IT market have improved tremendously over the past decade. Now, the new challenge facing healthcare stakeholders is how to most effectively fuel these analytics with a cohesive underlying data infrastructure that can appropriately supply data from all relevant sources. Within massive healthcare organizations, coalescing data from even their own disparate systems can be a challenge. Add in the relevant data that exists in the hands of other constituents across the care continuum, and there emerges an immense need for advanced data integration that can fuel accurate and real-time insights. As noted above, SDoH, typically indicated by non-clinical and often hard-to-capture data, introduces yet another critical and elusive non-traditional dataset that must be compiled and interpreted to enable optimal decision-making and insights. The challenge of developing a clean, comprehensive, and real-time dataset presents a monumental opportunity for the industry. While we see many vendors turning their focus to developing novel ways to aggregate this information, significant runway for improvement remains.
Reflecting on the past year, we have observed the growing importance of these themes as we’ve advised our clients and facilitated important industry transactions:
TripleTree is looking forward to engaging innovators, investors, and leaders converging at RISE, and we are excited to compare notes and share perspectives. See you in Nashville!
