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AHIP Institute 2013: Provider choreography

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Companies promising to help health insurers, benefit plan administrators and provider groups improve coordination of care may be even more visible at AHIP Institute 2013 than they were at the 2012 meeting.

Today, as America’s Health Insurance Plans (AHIP) kicks off its annual meeting in Las Vegas, insurers and plan administrators are more convinced of the likelihood that the Patient Protection and Affordable Care Act of 2010 (PPACA) will start to take effect more or less as written.


  • Requires insurers to hold sales and administration costs for individual and small-group plans to less than 80 percent of revenue.
  • Punishes hospitals that find that many of the patients they discharge soon return to the hospital.
  • Encourages Medicare to experiment with many new methods for reimbursing providers, such as “patient-centered medical home” programs and “accountable care organization” (ACO) programs, to encourage providers to do more to work together to increase the efficiency of health care.
  • Exposes many insurers, especially insurers in states that have been flexible about use of medical underwriting, to the possibility that they may see big increases in the number of high-risk and very sick people that they cover in 2014, because of provisions that will eliminate insurers’ ability to use personal health information in the sale of coverage and restrict insurers’ ability to use personal health information other than age in the pricing of coverage.
  • Creates new risk-adjustment mechanisms for individual and small-group plans that could reward plans that do a good job of increasing the efficiency of health care for patients who, in the beginning, appear to be high-risk patients.

Some vendors are making major plays to sell AHIP members entirely new information technology systems.

DST Health Solutions, for example, is pitching its Exeter 1.0 “next-generation enterprise payer platform.”

DST is not actually promising that the system will help with the Borb, but the system was developed with a modular approach, in an effort to reduce the risk involved with replacing core systems, and it should be nimble enough to help insurers “securely and rapidly exchange information with external channels,” the company said.

Other companies exhibiting at the AHIP meeting are focusing more narrowly on plan-to-provider connections, and especially data connections designed to support the new provider reimbursement arrangements associated with the care coordination programs.

PaySpan Inc. and Rx Management Inc. are showing a new program that is supposed to help physicians detect gaps in care management while seeing information about reimbursement. 

Inovalon Inc., a company that works with Florida Blue, will be talking about steps insurers can take both to improve quality and to improve the accuracy of enrollee risk scores, to increase the odds that they will do well in PPACA-related programs.

Some companies are offering patient-tracking tools. 

Outcomes Health Information Solutions L.L.C. is showing the SeniorCare advocacy program from a sister company.

The SeniorCare system can help plans identify patients with gaps in care who may need help from care coaches, or even from nurses or social workers who can visit them in person and see if there are ways to reduce the likelihood they will go to the emergency room, go to the hospital, or return to a hospital soon after leaving it.

Some companies have already been actively involved in applying the new approaches, such as ACO programs, and are sharing stories from the field.

Treo Solutions, for example, a consulting firm, is saying, based on its experience with ACOs, that communication, ongoing education, and easy-to-understand bursts of data are important to making an ACO work.

Organizations need to use claims data to find populations they can really help, Treo is telling insurers.

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