Analytic Solutions for Payers Payers have routinely looked at data from a non-clinical perspective, for intelligence and financial analytics. It's now time for payers to focus on leveraging next-generation analytics solutions. To reap the benefits that “Big Data” promises, analytic solutions must act as the core platform. In a recent survey, the need to manage new risk levels resulting from the ACA was the number one concern from respondents. The main solution that focus group participants identified for better management and understanding of issues related to the post enrollment risk environment, risk modeling and exchange risk structures: the leveraging of robust analytic solutions, like predictive and comparative analytics tools. Two national quality initiatives - Star Ratings program from CMS and the Healthcare Effectiveness Data and Information Set (HEDIS) from the National Committee for Quality Assurance (NCQA) are of particular concern in reporting and compliance, and payer analytics can play a significant role. …show more content…
As CMS increasingly relies on patient outcomes in establishing Medicare reimbursements to payers, they are using payers’ Star Ratings, as a key factor. For payers achieving the highest ratings of 4 or 5 stars, in 2012 they became eligible for bonus payments from CMS. Payers must also strive to work with providers to get members engaged in managing and improving their own health status. However, to be successful the top three analytics challenges were identified by a panel of experts: 1. Data Integration 2. Data Governance 3. Access to clinical