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Changes in Managed Care: The Role of Big Data in Consumer Choices

In this installment of “Ask the Expert,” we asked Dan Price to detail some changes in the Managed Care industry, and how he views the effects of those transitions moving forward. Mr. Price has several decades of Medical Management leadership experience, primarily within the financial and operational aspects of Managed Care. He has held multiple senior leadership roles, including Executive Director, VP, and Chief Financial Officer, at several different Payer and Provider organizations.

Written by Prashant Patel, Senior Search Consultant.
Contact him at 1.800.974.4828 x106 or prashant@carenational.com

CareNational was founded with the goal of assisting Health Plans, Hospitals, and their ACO or HMO-type mixed entities. We do this by providing boutique Medical Management consulting and recruiting support to help our clients properly staff their teams with the best Case ManagersUtilization Review Nurses and Quality Management Specialists. Managed Care has always been an evolving industry, today more than ever! Since 2010, we’ve seen tremendous changes within healthcare and we wanted to further that with a discussion of current and future modifications to the industry. We started by asking: What changes in the Managed Care industry are you dealing with on a daily basis, and what do you see on the horizon?

In this installment of “Ask the Expert,” we asked Dan Price to detail some changes in the Managed Care industry, and how he views the effects of those transitions moving forward. Mr. Price has several decades of Medical Management leadership experience, primarily within the financial and operational aspects of Managed Care. He has held multiple senior leadership roles, including Executive Director, VP, and Chief Financial Officer, at several different Payer and Provider organizations.

Mr. Price believes that one of the biggest changes in healthcare today, and a challenge that has yet to be adequately addressed, is the role publicly available big data plays in consumer choices. Across all industries, more and more choices by consumers are made based upon ‘recommendations’ of the general population often in the form of amalgamated reviews on websites such as Yelp or Angie’s List. Healthcare is no exception, and the industry is more competitive now than ever before. While subjective reviews and anecdotal stories will always give a sense of the feel of an organization, healthcare is in a somewhat unique position to give truly objective comparisons based on hard data collected and reported.

Hospitals and Health Plans have been gathering internal data for decades in order to support their own quality improvement efforts and increase value-based care. Those contracted with the Centers for Medicare and Medicaid Services (CMS), as well as related state-based programs, have had additional reporting requirements for some time. Examples include HEDIS on the national level, or QARR in New York state. This reporting aspect has only increased with the healthcare reform caused by the Affordable Care Act of 2010, sometimes referred to as ‘ObamaCare.’ In the age of social media reviews and rating websites, it is not enough to collect and report your quality metrics. It is the publication of that data that has become more and more of a requirement to compete.

The primary source for rankings of both federal programs (Medicaid and Medicare) and commercial insurance plans is the NCQA (National Committee for Quality Assurance). The purpose of this non-profit organization is to evaluate the quality of care provided by these health plans, based on established quality improvement criteria. They then conduct statistical analysis of the data and present their findings to the public. This can give the consumer insight on how well these plans serve their members’ needs. But it is not a perfect system, and data comparability and the definitions of the data elements have long been something of a mystery in the industry.
So how will the healthcare industry satisfy this need for consumers to make decisions on accessing care by using the internet for public data?

“Data comparability and reporting has been a requirement of the government for the 30+ years I have enjoyed participating in the industry and I have yet been able to provide a table of data that can be 100% accurately used to compare to others in the industry. It is a challenge yet to be solved.”

Special thanks to Mr. Price for providing all this great information. He is a highly experienced and educated healthcare professional with demonstrated success throughout his many years of working in Managed Care. If you would like to speak with Mr. Price about these topics, contact the author, Prashant Patel, Senior Search Consultant and Account Manager. Contact him at 1.800.974.4828 x106, or email him at prashant@carenational.com