How Are Health Plans Using Patient Data to Improve Outcomes?

Health plans collect enormous amounts of data through electronic health records, administrative claims, mobile health devices and other sources. Is the data simply sitting on a shelf, or is it being used to shape care delivery, improve system efficiency, and achieve better health outcomes?

Health plans collect enormous amounts of data through electronic health records, administrative claims, mobile health devices and other sources. Is the data simply sitting on a shelf, or is it being used to shape care delivery, improve system efficiency, and achieve better health outcomes?

A new assessment led by Avalere and the National Pharmaceutical Council found that the latter answer is true—health plans are using data in a variety of ways to enhance health care. Some approaches to data use and analysis are more routine in nature, such as managing medication use, while other approaches are more sophisticated, such as pulling together different data sources to develop value-based contracts.

The Avalere-NPC assessment identified seven ways that plans use data, including:

  • Engaging in value-based contracting between health plans and providers or biopharmaceutical manufacturers: Among health plans’ uses of data, the most advanced practice is value-based contracting, which aligns financial incentives with high-quality health outcomes at lower costs. These contracts tend to be complex, may be difficult to operate and measure effectiveness for, and do not guarantee controlled costs.
  • Developing predictive analytics to assess member health and potential gaps in health care: Another advanced use of data is to predict which patients might develop a particular condition, benefit from a treatment or assessment, or might not comply with treatment plans. Predictive analytics are in a fairly nascent stage. Some plans have internal staff and resources to perform these analyses, although many plans utilize outside contractors provide these services. This type of analysis could enable health plans and providers to anticipate the care needs of certain patients.
  • Developing clinical pathways and treatment protocols: The development of clinical pathways is also an advanced way to use data. Clinical pathways are intended to provide specific guidance on the types and sequence of treatments for a particular condition, such as cancer, and to reduce patient care variability and overall costs. Data is used both to inform care pathways by minimizing care variation and managing costs as well to monitor adherence to clinical pathways. 
  • Improving population health management: Health plans are using population health management for improved care coordination, provider-patient engagement and patient outcomes, all while controlling costs through targeted, preventive services. While more sophisticated data uses exist, most population health management plans are focused on disease management, implementing interventions in a more timely, proactive manner that can reduce increased costs such as emergency room visits.
  • Designing health plan provider networks: Another sophisticated use of data by health plans is to strategically develop preferred, high-performing networks, choosing providers and other sites of care based on quality, cost and occasionally patient satisfaction criteria. Their goal is two-fold: to provide patients with access to cost-effective, high-quality care within a localized region, while also reducing administrative burdens often associated with multiple vendors. Health plans also use this data to negotiate rates with providers.
  • Improving treatment rates and medication adherence: More routinely, health plans regularly review claims data to identify patients who might be at risk for non-compliance with prescribed treatment and medication regimens and target those patients with appropriate outreach and care management programs. Because patient behavior can be difficult to influence, health plans’ success with treatment and medication adherence programs vary widely.
  • Managing the utilization of medications, procedures, and surgeries: Health plans routinely direct care toward the most appropriate and efficient products and services through processes such as prior authorization, step therapy, drug utilization review, evaluation of both the intensity of services that are required and the severity of illness, and limits on the number of services or treatments during a certain time period. Utilization management has benefited health plans by decreasing costs and improving organizational financials, through the use of lower-intensity services and monitoring for potential fraud or system abuse.

Regardless of whether the data is used for routine or more sophisticated purposes, there are still staff, resource, and interoperability challenges for even the most sophisticated health plan or type of data. Plans must consider issues such as the need for skilled analysts to make sense of the data. Data may be stored in multiple sites which prevent comprehensive, real-time view of a patient’s conditions and medical status. In the future, data may be increasingly used to manage risk, engage providers, layer data to link non-medical sources, and develop smarter utilization management programs. However, special considerations also need to be granted to the patient data to ensure that it remains protected and is not misused.

As we think about emerging and future uses of data, it's important to understand where we are today and how data is and could be used to improve health system efficiencies and improve population health. All stakeholders have a role to play in this effort, whether it’s patients in understanding how their data is being used; providers on why documentation is important; policymakers designing incentives to create data interoperability; or payers trying to improve patient care and health plan efficiency. These examples of data use, whether a commonplace or novel activity for health plans, may benefit patients if the outcome results in lower insurance premiums or improved health and wellness.