Best Practices: Managing Post-Health Reform Challenges in Individual Health Insurance Exchange and Government Lines of Business

Best Practices: Managing Post-Health Reform Challenges in Individual Health Insurance Exchange and Government Lines of Business

This IDC Health Insights report provides a discussion of key trends, challenges, and best practices for payers and the IT vendors supporting individual insurance exchange, Medicaid, Medicare, and dual eligible lines of business. A post-health reform environment continues to bring regulatory and marketplace incentives for the expansion of all of these health insurance lines of business. The research in this report was obtained from discussions with health plan executives, vendor briefings, IDC Health Insights' own survey data, and reviews of publicly available case studies, reports, and analyses.

The future success of these corresponding payer lines of business largely depends on the ability of payer organizations to more effectively segment, analyze, and understand the healthcare and system navigation needs, motivations, and clinical care requirements. A much more targeted and comprehensive understanding of consumer population segments, particularly those serving vulnerable, high-cost, and high-risk population groups, is needed for payers to effectively administer and manage the delivery of care services. Another best practice area is the identification and development of partnerships with community and mental health services providers. Understanding and including considerations and provisions for health needs outside traditional hospitals and provider settings is key to better accommodate a 360-degree approach to member health and efficient care.

Payers and related vendors also need to closely monitor upcoming changes in 2015 as a direct result of political, regulatory, and emerging IT developments. For example, there may be forthcoming changes to quality measures out of CMS that include factoring in socioeconomic status and the impact this can have on key indicators, including hospital readmission rates. Payers and the analytics applications supporting these measures need to act accordingly.

"A post-health reform environment in the U.S. healthcare industry continues to offer evolving opportunities for change and the growth of individual health insurance exchange, Medicaid, Medicare, and dual eligibles lines of business," states Deanne Primozic Kasim, research director, Payer Health IT Strategies, IDC Health Insights. "Best practices from payers include bringing in consumer segmentation and analytics experience, often from outside of healthcare, to better understand the many demographic, socioeconomic, education, and community factors that must be managed in order to best reach and engage members in these lines of business. Leading payers are also developing mutually beneficial partnerships with community stakeholder groups and resources that can better support the 360-degree care of particularly vulnerable safety net populations. Accordingly, leading vendors are developing IT application capabilities that can accept and integrate value care-related information among all stakeholders, including consumers, and especially behavioral health."

Please Note: Extended description available upon request.

IDC Health Insights Opinion
In This Study
Situation Overview
Population Characteristics and Determinants of Health
Managing Individual Insurance Exchange Business
Quality Measures and Medicare Advantage
Managing the Growing Dual Eligible Populations
Managing Growing and Diverse Medicaid Groups
Business Needs
Medicare Advantage — STARS Ratings Changes
Improving Customer Service and Related Analytics
Management Challenges
Addressing a 360-Degree View of Member Health and Wellness
Medicaid Challenges
Medicare Challenges
The Best Practices
Individual Insurance Marketplace
Medicare and Dual Eligibles
Future Outlook
Essential Guidance
Actions to Consider
Actions for Vendors
Learn More
Related Research
Table: Payer Investment in Consumer-Related Analytics (% of Respondents)
Table: Consumer 360 Initiatives: Payers

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