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The healthcare landscape is undergoing a transformative shift towards the payvider model, driven by the imperative for enhanced care coordination, cost efficiency, and improved patient outcomes. Although the concept of payviders is not new, recent advancements in technology and a heightened focus on value-based care have sparked a resurgence in this integrated approach.

Unlike the traditional healthcare model, which often pits payers against providers in a bid to control costs, the payvider model merges these roles to provide more insights to direct care providers. This integration fosters a more patient-centered approach, aligning incentives across the care continuum and leveraging comprehensive data to deliver seamless, high-quality care.

So, who are payviders?

A payvider is an integrated healthcare entity that combines the role of a healthcare payer (often a health insurance company) and a provider (usually a healthcare delivery system).

In the traditional healthcare model, there is often a disconnect between payers and providers. This separation can create conflicting incentives, where payers aim to minimize costs while providers focus on the delivery of care, sometimes leading to adversarial relationships that are not in the best interest of patients. The lack of integrated insights can result in fragmented care, inefficiencies, and a less patient-centered approach.

Why become a payvider?

Being a payvider allows an organization to not only access but also own and control clinical, operational, and payment data. This control makes real-time access to this data much easier, enabling healthcare providers to make smarter decisions, offer personalized care, and manage health proactively. With comprehensive data control, payviders can easily and rapidly identify trends, improve forecasting, and swiftly adjust processes and policies. This integration leads to better patient outcomes, reduced costs, and more efficient, coordinated care. Embracing the payvider model positions healthcare organizations at the forefront of the evolving healthcare landscape, aligning perfectly with the shift towards value-based care, which prioritizes quality and efficiency in healthcare delivery.

Evidence and drivers of payvider growth

Pioneer payviders like Kaiser Permanente, Geisinger Health System (now part of Kaiser Permanente subsidiary, Risant Health), and Intermountain Health have seen significant growth, each increasing their membership by over 33% in the past decade. Newer entrants, such as UPMC and Providence, have experienced even more impressive growth, with over 70% growth in the last 10 years.

Strategic acquisitions highlight the growth of the payvider model. UnitedHealth Group, Elevance Health (formerly Anthem), Humana, and Cigna have been acquiring providers and systems to expand their integrated care networks. These acquisitions aim to enhance their ability to deliver coordinated, value-based care by integrating primary and specialty care, as well as other factors such as social determinants of health (SDOH), with insurance services.

Other organizations are entering the market and evolving towards the payvider model. The CVS Health acquisition of Aetna has integrated its insurance operations with its extensive network of retail pharmacies and healthcare services, including MinuteClinics and HealthHUBs.

Another significant driver is the expansion of Medicare Advantage (MA) plans. The Medicare Advantage market is rapidly growing, driven by the aging population and preference for integrated care options. More than 10,000 people age into Medicare every day, and the number of MA enrollees continues to rise. By integrating care delivery with the payment side of the equation, leveraging financial incentives to manage risk, focusing on value-based care, and tapping into a growing market with strong regulatory support, payviders can achieve improvements in care coordination, cost efficiency, and patient outcomes.

Delivering healthcare is hard

The promise of patient-centered care delivering better health outcomes while simultaneously reducing costs is a goal that the healthcare industry has long strived to achieve. Value-based care models have been around for decades, but delivering on that promise has been challenging.

Non-payer organizations made attempts to enter the market but have struggled to find success. Walmart announced their goal of opening 30 Walmart Health centers by the end of 2024, but has decided to close all 51 health centers across five states. Amazon, with its OneMedical offering, has recently experienced some leadership changes and layoffs despite its partnerships with some of the largest health systems in the country.

Healthcare organizations face numerous obstacles, from integrating complex data systems to managing financial risk and ensuring compliance with ever-evolving regulations. The transition from a fee-for-service model to a value-based care approach requires significant changes in how care is delivered, coordinated, and reimbursed.

  1. Complex data integration: Seamlessly integrating data from various sources, such as electronic health records (EHRs), claims data, SDOH, and patient-reported outcomes is a monumental task. Disparate systems and varying data standards make it difficult to create a unified view of patient health, which is essential for delivering coordinated, personalized care.
  2. Financial risks and sustainability: Managing financial risk is a significant challenge for payviders. The shift to value-based care involves taking on more fiscal responsibility for patient outcomes, which requires accurate cost predictions, robust financial reserves, and effective risk management strategies. Balancing these financial pressures while investing in quality care initiatives can be difficult.
  3. Regulatory compliance: Navigating the complex regulatory environment in healthcare is a continual challenge. Ensuring compliance with regulations such as HIPAA and HITRUST, and staying updated with changes in healthcare policies, requires dedicated resources and expertise. Non-compliance can result in significant penalties and damage to reputation.
  4. Care coordination: Coordinating care across multiple providers and care settings is essential for achieving better health outcomes, but it is also challenging. Effective care coordination requires seamless communication and data exchange between primary care providers, specialists, hospitals, caregivers and other healthcare and non-healthcare entities.
  5. Patient engagement: Engaging patients in their care is critical for improving adherence to treatment plans and achieving positive health outcomes. However, motivating and enabling patients to take an active role in their health can be difficult. Healthcare providers need to leverage technology and personalized communication strategies to enhance patient engagement.

Payviders’ guide to success

The payvider model offers a promising approach to healthcare by integrating payer and provider roles. To be successful, payviders must excel in several key areas, with effective data management playing a critical role.

  1. Integrated care delivery and coordination: Successful payviders ensure seamless coordination between various healthcare services, from primary care to specialty and post-acute care. This integration reduces fragmentation, improves patient outcomes, and enhances the overall patient experience.
  2. Value-based care: Emphasizing value-based care is crucial. This means focusing on the quality of care rather than the quantity of services provided. Payviders are incentivized to improve patient outcomes while controlling costs, aligning their financial goals with the health needs of their patients.
  3. Patient-centered approach: A patient-centered approach is at the heart of the payvider model. This involves understanding patient needs, preferences and health goals, and tailoring care plans accordingly. Engaging patients in their care journey leads to better adherence to treatment plans and improved health outcomes.
  4. Robust financial management: Managing financial risk effectively is essential. Payviders need sophisticated risk management strategies, including accurate cost predictions, appropriate premium setting, and financial reserves. This ensures sustainability and the ability to invest in quality care initiatives.
  5. Regulatory compliance: Staying compliant with healthcare regulations is non-negotiable. Payviders must navigate complex regulatory landscapes, ensuring they meet all requirements related to patient privacy, data security and reporting standards.

Role of data management in successful payviders

At Neudesic, we understand the that access to the right data at the right time as a cornerstone of the payvider model, enabling the integration of care delivery and insurance functions, and supporting several key aspects:

  1. Comprehensive patient data integration: Data from various sources – such as electronic health records (EHRs), claims data and patient-reported outcomes – must be integrated to provide a 360-degree view of each patient. This holistic perspective enables more accurate diagnosis, personalized treatment plans, and better care coordination.
  2. Advanced analytics and predictive modeling: Advanced data analytics and predictive modeling allow payviders to identify at-risk patients, predict healthcare needs and allocate resources efficiently. By analyzing patterns and trends in patient data, payviders can implement preventive measures and early interventions, reducing healthcare costs and improving outcomes.
  3. Interoperability and data exchange: Seamless interoperability between different healthcare systems and EHRs is crucial. Payviders leverage standards like HL-7 FHIR to ensure efficient data exchange and coordination across various care settings. This interoperability enhances communication among providers, enabling the provider to access the right information at the right time, leading to better coordinated and timely care.
  4. Enhanced patient engagement: Data Management tools enable payviders to engage patients more effectively. Patient portals, mobile apps and other digital tools allow patients to access their health information, communicate with providers and participate actively in their care. This engagement is key to improving adherence to treatment plans and overall health outcomes.
  5. Regulatory and compliance reporting: Accurate and timely data management is essential for meeting regulatory and compliance requirements. Payviders must ensure that data is secure, accessible, and accurately reported to regulatory bodies. This involves implementing robust data security measures to protect patient information and ensure compliance with HIPAA, HITRUST, and other regulations.

Successful payviders put their members first with a focus on member enrollment, point of care transitions and payment coordination. To ensure that goals and interests align, communication between payers, providers and patients is key, and we offer solutions to enable your organization to meet their goals.

  1. NeuCare is a care management platform which provides a 360-degree view of all patient data and relationships, alongside transactional data, ensuring informed and personalized interactions. Our person-centered design and planning focus on meeting the unique needs of each patient, driving better health outcomes and satisfaction.
  2. Purpose-driven healthcare data solution: Our solution includes an Open Common Data Model and the Microsoft Cloud for Healthcare Common Data Model – HL7/FHIR to ensure seamless data integration, enhanced interoperability and accelerated digital transformation.
  3. Provider data management solution: This solution streamlines onboarding, credentialing, contracting and network operations. By optimizing these processes, we help you maintain compliance and operational efficiency.

All Neudesic solutions are designed to comply with regulatory requirements easily and efficiently, empowering your organization to scale and thrive in the rapidly evolving healthcare environment. Contact us today to learn how our solutions can transform your organization and help you achieve your goals. Together, we can create a more integrated, efficient, and patient-centered healthcare system.

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Security is an imperative for every industry and company—and in the healthcare industry it is especially critical.

In addition to the same security concerns every industry has about information and data privacy, the healthcare industry also has enhanced regulatory and ethical requirements related to the privacy of healthcare information.

According to some sources, about 30% of the world’s data volume is being generated by the healthcare industry.1 This data includes information that is particularly vulnerable to security breaches such as Personal Health Information (PHI), Personally Identifiable Information (PII), and patients’ financial information. For decades, there has been an attempt to consolidate all of these sources of personal information through efforts like statewide Health Information Exchanges (HIEs), that would make it easier for patients and their various healthcare providers to have all of the patients’ information in one shared location. By sharing patient information with other healthcare organizations, however, patients’ personal information and data becomes extremely vulnerable–and extremely valuable–for those wishing to profit from its acquisition.

1Wiederrecht, G., Darwish S., Callaway A., The Convergence of Healthcare and Technology. RBC Capital Markets.

What is the current state of security in the healthcare industry?

Right now, the healthcare industry is a unique combination of cutting-edge technology and aging legacy systems like spreadsheets and manual data input. While patients are embracing technology like health apps and demanding easier access to their personal health information, healthcare organizations are being pushed to up their own technology game.

As technology advances, however, so do the security concerns that span all industries—the threats of hackers and those with ill intentions trying to gain access to entire networks of information illegally. Connecting networks of data creates better access for healthcare organizations and patients, yes, but it also creates the opportunity for hackers to gain that same access to valuable information. Healthcare organizations have been experiencing escalated costs related to data breaches. In 2020 alone, healthcare data breaches cost $13.2 billion, which is over double the amount of the annual data breach cost of $6.2 billion in 2017. In response to these breaches, regulators are increasing pressure on healthcare organizations to improve security and compliance–but they aren’t providing the funding for the healthcare organizations to do so.

The healthcare industry is also facing the challenge of every healthcare organization having different security protocols and processes. With various degrees of security measures in place, healthcare organizations lose the ability to effectively secure and manage their data widely. A prime example of this is the HIEs and the security situations they create by trying to consolidate patient information. The HIEs bring patient information together so that patients, providers, and payers can interact with the information directly and share it between cooperating and competing organizations. In doing so, however, the patients’ information is now at the discretion of many organizations who may or may not be as secure and compliant as the organization that originally gathered the patient information, which could then compromise how secure the data remains.

So, how can healthcare organizations prepare for future security risks and threats?

To protect their patients’ vulnerable information, healthcare organizations must invest in technology and processes that bolster the security of that information.
In addition to increasing their own security maturity, healthcare organizations must enhance regulations that enforce security and compliance standards to resolve the issues of when patient data is shared.

The Neudesic Care Management Platform helps healthcare organizations meet their security challenges and protects patient information from future security threats. Built on Microsoft Cloud for Healthcare, Neudesic’s Care Management Platform incorporates security best practices to protect information. It uses a rich security model to protect the data integrity and privacy of users while promoting efficient data access and collaboration.

The platform is ideally suited to strengthen and improve healthcare ecosystems and promotes sharing patient information securely. It combines business units, role-based security, row-based security, and column-based security to define the overall access to information, while also meeting the healthcare industry’s compliance and regulatory requirements.

A platform built for better outcomes

Neudesic’s Care Management Platform is already improving patient care and business outcomes for healthcare organizations. The platform is helping increase security and building confidence in healthcare providers, payers, and patients by:

  • Reducing risk by 70% through improved case management and elimination of information gaps.
  • Reducing payment errors and missed payments by more than 90% through batch generation.
  • Reducing process overhead by 30% by streamlining processes and eliminating data re-entry.

Information security is an ever-present threat to all industries. For healthcare organizations, the Neudesic Care Management Platform is helping secure vital patient data and improve healthcare delivery.

About Neudesic

Neudesic is the trusted technology partner in business innovation, delivering impactful business results to clients through digital modernization and evolution. Our consultants bring business and technology expertise together, offering a wide range of cloud and data-driven solutions, including custom application development, data and artificial intelligence, and comprehensive managed services. Founded in 2002, Neudesic is headquartered in Irvine, California.

Read our full Blog to learn more.

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Health systems are experiencing a shift right now. Moving from a focus on the quantity of services to the quality of those services, health systems are promoting a higher quality of care for patients. And one way they’re doing so is by forming Accountable Care Organizations (ACOs).

What are ACOs?

ACOs are groups of doctors, hospitals, and other health care providers who voluntarily contract to share responsibility for the quality, cost, and coordination of care for a defined population of patients.

To share a patient’s care across all of the members of an ACO, communication and coordination are essential. Seamless communication not only ensures that every doctor, hospital, and health care provider knows exactly what’s going on with the patient and the services the patient needs, but strong communication creates efficiency within the health system itself and ultimately creates a better outcome for the patient by giving them the right care, at the right time.

Strong communication that leads to better care coordination amongst an ACO is also helping to address gaps in patient care. These “care gaps” currently exist when there are multiple services being used to manage a patient’s care and connections are missing between the services themselves. Take, for example, a patient going into a hospital for a procedure, and though they are planning to be an inpatient for three days, they get released one day early. Without interconnected care coordination services, there may not be transportation booked for the patient to move to their living arrangements or an outpatient rehabilitation center, creating a gap in their care. Now the patient and their health care providers must scramble to get the patient to where they need to go next for proper recovery, impacting the patient’s outcome and their overall healthcare experience.

Where else do these care gaps happen?

As ACOs require each entity to maximize the efficiency of their care delivery to maintain margins, the individual parties who make up an ACO are motivated to communicate and coordinate with one another as much as possible.

When an ACO is successful, it creates better patient care coordination, which in turn bridges information and communications, and monitors the gaps in care to minimize them as much as possible. Successful ACOs deliver high-quality care and spend healthcare dollars more wisely, thus sharing in the savings it achieves for the payor, such as Medicare or private insurers.

Creating a holistic patient view to close care gaps

To help ACOs fulfill their purpose and create seamless patient care coordination, Neudesic’s Care Management Platform combines patient data across multiple platforms and allows ACOs to get a holistic view of their patients and their care journeys.

The Care Management Platform allows ACOs to understand how their specific patient outcomes can be tied back to behavioral health, and allows them to see how plans can be created and predicted to allow for better patient outcomes and satisfaction.

Along with minimizing care gaps in the patient journey, the Care Management Platform enables ACOs to work toward their ultimate goal: ensuring patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

About Neudesic

Neudesic is the trusted technology partner in business innovation, delivering impactful business results to clients through digital modernization and evolution. Our consultants bring business and technology expertise together, offering a wide range of cloud and data-driven solutions, including custom application development, data and artificial intelligence, and comprehensive managed services. Founded in 2002, Neudesic is headquartered in Irvine, California.

Read our full Blog to learn more.

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For years now, healthcare providers have been searching for a single, comprehensive patient record, or what has been termed “The Golden Record.” The Golden Record is a desired state, it’s a term that doesn’t capture the full importance and impact of a comprehensive record, and at the moment, it’s an elusive goal.

Patients often have multiple medical records for a variety of reasons including regulatory requirements that need the system of record to be the same as the source system. Sometimes, patient data is entered in the place of service for localized use only, and those entering the data may not have a central Electronic Medical Record (EMR) system. And there are scenarios when patients are authorized caretakers of family members and friends, which requires an additional record that’s not the patient’s own to now be part of their file. The “golden record” attempts to create single record for patient but does not provide comprehensive view.

The goal behind the comprehensive patient record is to collect these duplicates of a patient’s record, and bring them into a single, all-encompassing record that houses their data in one spot. Additionally, the Golden record just provides partial truth around the patient. The patient care is from variety of sources beyond the EMR record. The data may exist from in-home, nursing facilities, wellness centers that are part of the care management, but information are not usually connected due to nature.

So, what’s stopping a comprehensive patient record from happening?

Creating a single comprehensive patient record is challenge when the EMR captures the encounters that are within the provider locations (assuming provider has single EMR system across its network).

The build of analytics and datawarehouse system has provided some initial foundation on building comprehensive patient record but that can be time consuming and may be limited for more long-term care.

We’ve seen that Master Patient Indexes (MPIs) within EMRs are exceedingly limited in their ability to compare records from disparate sources. And as some EMR systems inadvertently duplicate patients’ information, multiple individual records are created when the EMRs lack the sophisticated algorithms that compare and link records across different data sources and locations.

Despite these challenges, though, healthcare providers are making progress toward the comprehensive patient record by using Continuum of Care records. These Consolidated Clinical Document Architecture (C-CDA / HL7 v3) has provided the clinical documents that providers can ingest into its EMR systems for building comprehensive patient record. However, this data is restricted to either digital scan documents (some providers get faxes) or structured encounter data that was provided via interoperability. The challenges still continue on bringing encounter data that is not EMR, for example, at-home care, wellness centers, outdated medication (Over the counter (OTC) and/or Prescription).

The promise of a comprehensive patient record

With a comprehensive record, all healthcare service providers have a common, shared dataset and patient profile.

The comprehensive patient record can also alleviate the inconveniences, frustration and stress patients feel when their records aren’t able to be found at a location, and they’re forced to re-register. When their information can be easily accessed, and they do not need to fill out the same paperwork multiple times. The comprehensive patient record also helps eliminate multiple unnecessary tests, misdiagnosis. The longitudinal view of patient is available for providers to better patient care, patients have improved experiences and better outcomes overall when it comes to healthcare.

There are many benefits for healthcare providers as well. With a comprehensive patient record in hand, healthcare providers have the capability to understand their patients completely, and thus provide better services. Providers can also answer questions such as:

  • What are the Social Determinants of Health (SDOH) for the consumer?
  • What are the factors that help deliver better quality services and reduce the risks for pre- and post-care?
  • Where do gaps exist in services that are being offered?

How can we make the promise of a comprehensive patient record a reality?

Artificial Intelligence-based algorithms can help make progress toward a comprehensive patient record by matching criteria used in multiple systems.

There are algorithms that can provide matching capabilities using deterministic and probabilistic methods, and these algorithms are built into modern tools that can help combine data from multiple sources into a “belly button” patient record. Building out these algorithms to include external social data and automate processes that reduce the need for manual intervention will be huge steps toward the comprehensive patient record becoming reality. Using, FHIR API capability to ingest data from external compatible system provides building complete comprehensive record on the platform. The data from non-encounter transactions, outreach calls, medication follow-ups would help clinicians and care providers improve overall healthcare delivery.

Neudesic’s Care Management Platform is further helping realize the promise of a single, comprehensive patient record as an interactive platform that enables shared communications between consumers, vendors and community care providers. Built on the Dynamics Cloud for Healthcare, the Neudesic Patient Reactivation Solutions are helping providers and healthcare organizations to:

  • Identify patients for Care Management based on consolidated patient data and segmentation
  • Target outreach to engage patients with care journey management tools
  • Optimize scheduling via self-service portals, virtual agents, email and text
  • Track data to calculate ROI generated by new appointments

This work to bring together fragmented and duplicated patient information into a single, comprehensive record is the ultimate goal because the better the patient record is, the better the care the patient receives.

About Neudesic

Neudesic is the trusted technology partner in business innovation, delivering impactful business results to clients through digital modernization and evolution. Our consultants bring business and technology expertise together, offering a wide range of cloud and data-driven solutions, including custom application development, data and artificial intelligence, and comprehensive managed services. Founded in 2002, Neudesic is headquartered in Irvine, California.

Read our full Blog to learn more.