Outcomes-Based Reimbursement Model
For several years, Humana has been transitioning from a fee-for-service model to an outcomes-based model The company has invested heavily in technology to improve its data mining and analytic capabilities. Humana established a subsidiary, Transcend Insights™ to pool and analyze information from multiple health record databases to provide proactive patient care.
Transcend Insights™ is an integral part of Humana’s transition away from reactive care to an outcome-based model. Transcend Insights™ seeks to move the reimbursement model from “volume to value” through the use of “real-time health care analytics and intuitive care tools.”
For example, Transcend Insights™ can immediately alert a physician to a drug contraindication or if a patient is due for an annual health screening. The system and associated platforms generate an alert when it identifies a gap in treatment or cost-saving opportunity.
With Humana’s use of Transcend Insights™ and its other proprietary data analytic platforms, the insurer can process vast amounts of data in search of ways to cut costs, reduce risk, streamline healthcare delivery and improve patient outcomes. Some medical professionals welcome the time-saving assistance this technology brings so long as the final diagnosis or treatment decision rests with them.
Data-Driven Clinical Decision Support Systems
Humana has moved to put all of its data into a clinical infrastructure called “CareHub™.”
CareHub™ is intended to optimize the insurer’s ability to affect care and change provider and patient behavior by using predictive insights to create actionable health intelligence at the point of care. This technology has many uses, such as preventing an acute event from happening which can improve patient outcome and reduce costs.
Before CareHub™, a 2016 internal Humana report identified 3.8 million healthcare gaps annually by analyzing 2.5 billion pieces of clinical data per day.
CareHub™ communicates throughout the day with care providers through multiple channels. The technology provides physicians with a comprehensive view of each patient’s medical profile. Access to this information provides medical teams with actionable data to improve outcomes and reduce overall care costs.
Artificial intelligence, neural networks, and algorithms are now being used by health insurance companies and medical professionals to review everything from pathology reports to sepsis risk. Industry analysts predict that by 2021, the health care AI market could reach $6.6 billion.
These platforms are yet another means by which the health insurance company can direct patient care. There are concerns that failure to follow the technology’s recommended treatment or protocol may impact reimbursement models. These are real concerns to be addressed as the confluence of technology and healthcare increases.
Privacy Concerns
Privacy advocates have concerns about how insurance companies are collecting and analyzing patient data within these new platforms. Access to these vast databases will no doubt be a target for hackers. The fallout from the release of millions of patient’s data would be disastrous if it found its way into the wrong hands.
Humana states that it has implemented policies and procedures to ensure the privacy of confidential patient information, throughout the process of analyzing data and providing clinical intelligence. The company claims that its use of information collected through these systems complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all other federal and state laws.
