Healthcare’s Data Frontier: Accelerating Success through Data Analytics for Payers and Providers

August 21, 2023 By: Asmita Pillewan

Digital Transformation in healthcare has led to the development of electronic data in different formats. With the growing availability of data, analytics around data has become a buzz in the market. Data Analytics generates insights that are beneficial for decision-making in business. Healthcare has exponentially used data to optimize clinical and administrative processes, enhance revenues, and contain cost.

Payers have utilized analytics to accurately identify high-risk patients or forecast future expenses associated with their care to manage the risk. They have used clinical and claims data to understand the utilization and healthcare spending. Providers are using this data to visualize their performance, understand and predict disease profiles for patients, and plan early intervention to save more lives and improve care delivery.

Research shows that healthcare analytics has grown exponentially over recent years, now boasting a global market value estimated at $74.62 billion by 2028 – which can result in an impressive reduction of up to 30% in costs when implemented correctly. In parallel with the exponential growth of data analysis, healthcare big data practices will increasingly augment clinical practice with predictive capabilities.

Data Analytics for Payers & Providers – Areas of Implementation

Due to demographic transition, old age population is increasing and contributing to high cost of healthcare. Payers are under immense pressure to control healthcare spending while maintaining the quality of care. However, fragmented data systems can hinder obtaining accurate and timely information. Advanced analytics solutions for healthcare can efficiently process unstructured datasets and uncover real-time cost reduction strategies, driving more efficient operations. Let us explore some benefits for payers.

Fraud, waste, and abuse are major hazards to payers, they extensively rob payers with overutilization of resources and diversion of resources to wrongdoers, and unnecessary costs to federal programs. Identifying fraud, waste, and abuse involves the analysis of extensive claims data to identify suspicious patterns indicative of fraudulent activities. This process employs predictive modeling and machine learning techniques to forecast the likelihood of fraud, expediting investigation efforts. Real-time monitoring and network analysis aid in promptly identifying suspected fraudulent claims and revealing connections within fraud networks. Collaboration and data sharing among payers, law enforcement agencies, and regulatory bodies strengthen the effectiveness of fraud detection capabilities.

Population health management utilizes healthcare data analytics to empower payers in effectively managing the well-being of their covered populations. By analyzing population health data, payers can identify vulnerable individuals, evaluate health trends, and determine optimal care interventions to improve health outcomes. Data analytics enables payers to stratify risk and identify high-risk individuals who would benefit from further care management and preventive interventions. Predictive analytics facilitates proactive anticipation of future healthcare needs, enabling resource allocation accordingly. Prominent healthcare solution providers like JK Tech offer population health analytics to support payers in assessing care interventions and optimizing population health strategies based on data-driven insights.

Risk adjustment is a crucial part of payer’s business processes, it helps payers to determine disease burden and get expected funds from CMS. AI/ML tools like NLP help to extract meaningful and relevant information from EHR data which helps to calculate risk score and optimize funds for Medicare Advantage Organization.

Quality improvement is another area where healthcare data analytics plays a vital role, helping to reduce issues related to quality improvement and optimize provider networks for payers. By extensively analyzing healthcare data, analytics can uncover inconsistencies in care, evaluate performance metrics, and identify areas for improvement. This enhances payers’ ability to assess the quality of care provided by healthcare providers and identify avenues for enhancing patient outcomes. Data analytics also enables providers to optimize their networks by thoroughly assessing provider performance, cost efficiency, and patient satisfaction. The insights gained through data analytics guide payers in making informed decisions regarding network inclusion, contract negotiations, and the implementation of value-based reimbursement models, ultimately improving their provider networks and enhancing patient care overall. Different quality measures like HEDIS, STAR have complicated reporting patterns and need to understand data thoroughly to identify care gaps and to report accurately. JK Tech’s data aggregation and data enablement capabilities help to consolidate required data and improve reporting of quality measures to gain higher incentives.

In pursuing high-quality healthcare and improved outcomes, data analytics is an indispensable tool for healthcare providers as well. By analyzing both current and historical data, organizations can glean insightful information to support decision-making at any level from optimizing drug regimens to reducing emergency visits and improving cost efficiency.

Additionally, digital healthcare solutions like telemedicine and electronic medical records are utilized to enhance patient access and payment models incentivize value-based care. JK Tech’s expertise in aligning investment in technology initiatives with the use of analytics tools for informed decision-making, allows healthcare providers to achieve optimal results in delivering quality care while reducing expenses.

Healthcare data analytics plays a crucial role in improving various aspects of healthcare. Firstly, it enables better coordination of care by providing valuable insights into patient populations and identifying gaps in care. It utilizes extensive datasets to facilitate communication, simplify workflows, and ensure relevant patient data is accessible to all stakeholders. By analyzing data, healthcare providers can pinpoint inefficiencies, optimize resource allocation, and enhance care coordination, resulting in improved patient outcomes.

Secondly, healthcare data analytics enables providers to avoid diagnostic errors by providing clinical decision support system with the prediction of the onset or recurrence of disease. With this approach, false positives can be prevented and the cost of several tests can be saved. Through the analysis of large volumes of healthcare data, including electronic health records, claims, and SDOH, predictive indicators can be identified. This allows providers to target preventive interventions, implement early interventions, and allocate resources more efficiently, leading to improved health outcomes and cost savings.

Lastly, healthcare data analytics plays a crucial role in personalized medicine. By leveraging biomedical big data, such as genomic information and medical records, providers can extract valuable insights and patterns for personalized treatment plans. Gene therapy developed for breast cancer is a good example of personalized medicine. Through extensive analysis of patient’s genetic profile, individual characteristics, risk factors, and treatment responses can be identified, optimizing, and individualizing medical care. Data has the potential to accelerate the drug discovery process with evidence generated at different points of workflows.

With healthcare analytics becoming an ever-more integral part of the healthcare industry, payers and providers can now measure population health metrics more effectively while aiding decision-making at both patient and business levels. This shift towards a value-based care model allows for improved risk management in light of high-cost memberships, as well as potential improvements when it comes to cost structures coupled with better outcomes on behalf of patients. Nonetheless, pertinent concerns must be taken into consideration; acting solely with these tools focusing purely on profitability may leave out other important aspects within healthcare.

About the Author

Asmita Pillewan

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