The healthcare world is in the middle of a data revolution of sorts. Both providers and payors are starting to realize that their transactional systems contain a wealth of data that can be used for strategic advantage. Many organizations are spending considerable time and resources in standardizing, cleansing and remediating data issues in their transactional systems to be able to leverage this data to drive improvements in quality of care, financial efficiencies, operational effectiveness and innovative research. However, in many cases, organizations are potentially missing one of the most critical components: the integration of clinical and financial data.
Both provider and payor organizations individually realize the value of their data. However, even in the case of a provider with a health plan, both sides tend to view their data in isolation, thus missing the benefits of integrated data. Integrated clinical and financial data offer a wide range of benefits, including the ability to have a:
More Complete View of the Patient Experience
In today’s competitive healthcare landscape, the patient experience cannot be underestimated. Consumer’s have increasing choices of where to get their healthcare services (hospitals, private practitioners, community health centers, urgent care facilities, etc.). If there isn’t a significant difference in the cost and/or quality of care, consumers tend to go to where they feel comfortable.Comprehensive Cost Picture vs. Outcomes
For years, healthcare organizations have been trying to understand the true cost of the services provided. The increased focus in areas such as surgical analytics, materials management, etc. are attempts to gain an understanding of the cost of treatment choices made vs. the outcomes derived. However, this focus only goes part way. A true comprehensive cost vs. outcome analysis requires including the health insurance side of the equation. By having this complete picture, organizations can drive costs down without impacting quality of care. In fact, in many cases, the costs go down while the quality care goes up. Consumers are savvier today than in the past. With the wealth of comparative information available today, consumers can make more informed decisions on where to get their healthcare services.Complete Longitudinal Record of a Patient
Statistics show that people are receiving more healthcare services today than they have in the past. Additionally, there is a greater emphasis on preventive care as part of an individual’s healthcare plan. Understanding the complete lifecycle of a patient thus becomes critical in developing and evaluating a patient’s progress. While the clinical systems provide a great deal of the base information for a longitudinal view of a patient, health plan data can complete the picture and provide additional insights that might not be apparent with a clinical system only view.
So why haven’t more organizations pursued integrated clinical and financial data? There are a number of reasons I’ve heard over the past couple of years. For some organizations, the provider and payor worlds use different terminology and it’s difficult to create the link. For others, it’s the perceived cost vs. payback to integrate the data. While for others, it’s the lack of prioritization for such an initiative. Whatever the reason, the cost of not having the integrated view can result in significant adverse consequences. Examples include:
No Real Way to Tie Comprehensive Cost to Outcome
Without a comprehensive cost picture, informed decisions on equipment and materials usage, treatment protocols, etc. vs. outcomes cannot be truly and objectively be made. This can result in significantly higher treatment costs that do not result in improved outcomes.Inefficient Claims Processing
Without a common terminology between provider and payor, claims processing costs can be significantly higher than necessary. Double processing of claims, increased claims administration, etc. can drive up overall cost and reduce profits.
Increased administrative costs on both sides due to inconsistent interpretation of data
As an extension of above, inconsistent terminology can significantly increase administrative costs on both the provider and payor side. Investigation of differences, reconciliation of results, etc. can require significant person-hours to perform the necessary activities.Decreased Patient Satisfaction
Most people at one time or another have probably dealt with the hassles with insurance claims. Something as simple as trying to tie an Explanation of Benefits statement to the services provided can be demanding. With the choices offered to consumers today, frustrating consumer experiences can drive patients to investigate alternative providers and insurance providers.
The good news is that the organizations are starting to realize the benefits of integrating clinical and financial data. This fact, coupled with increasing competitive and regulatory pressures, is driving organizations to act on initiatives to provide more coordination and integration of the clinical and financial data. Examples include:
- 4010/5010 – Expanded HIPAA codes shared between the two sides
- ICD-9/ICD-10 – Expanded diagnosis codes shared between the two sides
- Health Information Exchanges – Intra- and inter-provider/payor sharing of patient information
- Outcome Based Medicine – Push to base compensation/reimbursements on outcomes or Pay for Performance
- Advanced analytics on chronic disease management with new ICD-10 code granularity (more detail equals more sophisticated analysis)
The bottom line is that, although some organizations are starting to realize some of the benefits of having integrated clinical and health plan data, the leaders are exploiting this data for their strategic advantage. Organizations that are not actively pursuing this strategic approach will be at a competitive disadvantage. As the pressures increase to control administrative costs and spend more on clinical outcomes, integrated clinical and financial data will rise to the top of organizational priorities.
