Health Plan Use of Patient Data: From the Routine to the Transformational


As the abundance and variety of patient data elements and sources continue to grow, health plans seek opportunities to deepen insights from multiple sources of patient data to shape care delivery, improve system efficiencies, and achieve better health outcomes. However, there is still considerable work to do in order to achieve health systems’ transformational goals. Based on interviews with executives within health plans and third party sources that support these efforts, we present a framework for how patient data is used to improve care. We identify seven use cases, each with distinct benefits, limitations, impact, and resource requirements (e.g., data infrastructure and/or staff), on how health plans use data. Use cases range in sophistication from routine source approaches to sophisticated multi-data source care management applications. Even within a given data use, plans vary in the sophistication of data analytic capabilities, and in approaches to applying it to care delivery, system efficiency, and patient outcomes.

The health plans we surveyed identified many challenges – for which solutions could improve insights and the efficiency of care. These include: varying documentation requirements, lack of integration and coordination between data stored within or outside of the electronic health record (EHR), and misalignment of incentives between providers who deliver care and generate clinical data, health systems reporting care, and health plans who pay for care. We highlight data benefits to improve care and care efficiency; concurrently, we highlight potential misuses of patient data.