America’s healthcare system is preparing for the entry of millions of new members as enrollment opens for health insurance exchanges. This influx will put even more pressure on payers and providers to develop higher-quality, lower-cost care delivery and reimbursement models. Health plans must prove their value while keeping administrative costs low and medical costs under control to compete in this price-sensitive business-to-consumer market.

As the marketplace evolves, the real challenge will be ensuring that current systems are able to manage clinical and financial interactions in an efficient, cost-effective way. Payers will be challenged to attract a balanced set of healthy and at-risk members. They’ll need to create tailored networks and plans for the new waves of new customers seeking coverage, and they’ll need to do this in an industry already challenged by complexity.

Health plans can address these exchange challenges by breaking them down into four cornerstones of success, each of which requires clinical evidence and expert technology to be achieved.

  1. Effectively manage provider networks. The ability to quickly create targeted provider networks that steer members to cost-efficient, high-quality caregivers while maintaining care accessibility is an essential competitive requirement.
  2. Ensure appropriate, high-quality care. More than ever, plans need actionable, evidence-based intelligence shared in an automated workflow with providers to help determine whether care is medically necessary and delivered in the ideal setting.
  3. Engage members and carefully manage their care. Coordinated care across the delivery system and high-impact care management ensure that members are connected to services and support that will help them maintain and improve their health. This reduces unnecessary ER visits, hospitalizations and readmissions.
  4. Optimize medical policy and payment. As plans aim for more competitive pricing, payment needs to be administered with the utmost precision, no matter how complex the medical and payment policies in place. This also builds trust from providers, something critical to maintaining transparency and reliability amid a plan’s network.

Plans that deal with these imperatives will do more than successfully compete in the consumer-driven exchange market. They will gain the contemporary infrastructure and knowledge that can drive long-term sustainability and positive impacts across all markets, not simply the exchanges.

About the author: Emad Rizk, M.D., president, McKesson Health Solutions, is a world-renowned healthcare industry expert with a focus on transformational strategies and operational execution through healthcare information technology.

Four keys to success in health insurance exchanges
By: HMT Mag
The Source for Healthcare Information Systems Solutions