Bringing Real-time Payer-Provider Collaboration to Life with Humana
by XSOLIS Insights, on Sep 18, 2020 6:00:00 AM
Healthcare can’t remain a zero-sum game. Earlier this week, XSOLIS CEO Joan Butters joined George Renaudin, SVP at Humana, and Doug Ghertner, CEO at IVX Health, for a frank discussion on the state of today’s payer-provider relationships.
Their conversation covered three arcs: zooming out to the status quo and why it can’t stand; zooming in to what XSOLIS and Humana are doing to transform the discipline of utilization management; zooming back out to how the industry can adopt this forward momentum.
In healthcare, three broad areas of opportunity are gaining momentum: settings of care, value-based care, and data and communication. COVID-19 has substantially accelerated the move to telehealth and even before 2020, volume at acute care facilities was trending downwards. This shift from volume to value has been seen across multiple channels, though the industry-wide dollars tied to value-based arrangements are still relatively minor. As healthcare leaders at both plans and systems look to better understand the first two areas, the third, data and communication, become even more critical. All three panelists explored this third area deeply. George details stories of Humana acquiring provider-owned health plans and comparing the utilization management data these plans had when provider-owned to what was accessible post-sale: “that [data and access] went away.” His response was to search for a strategic partner who could replicate that approach: “How do we find a solution that can give us that exact same kind of integrated capability that we had?... In searching out for that solution, we came across [a health system partner, Covenant Health, using XSOLIS].”
At its core, utilization management seeks to balance the cost of care with the appropriate level of reimbursement, all in the patient’s interest. XSOLIS was started with this mission in mind and has found itself supporting both payers and providers to make UM more data- and analytics-driven. As Doug shares, data can be a unique bottleneck because, “at the end of the day, decisions are being made based on the data folks have in the moment…even if both payers and providers have the same information, oftentimes one of them has it sooner than the other.” Many times that shared information is nowhere to be found. Without a common framework of data, each party is practically speaking a different language.
Early work with Covenant Health in TN and Humana was crucial to setting up this framework. Staff from both organizations could use XSOLIS’ technology platform, CORTEX, as their real-time guide for medical necessity determinations. CORTEX extracts data from the electronic medical record and applies natural language processing and machine learning to give staff a continuously updated view of each patient’s clinical picture. Humana has expanded its collaborative provider CORTEX-based partnerships across six states and counting. As George shares, with CORTEX “you as a provider and you as a plan are looking at the exact same information at the exact same time…there’s no need to send that information, the other party can just go and look at it. That kind of effective communication is just so vitally important to all that we do.”
The success between Humana and its provider partners is an indication of something new and positive afoot: evident change and real collaboration. Standardization, digitization, communication, analytics and consumer-centricity are all poised to play a massive role in shaping the future of healthcare: a future that is data-centered, analytics-driven, patient-friendly, and cost-efficient.
Let’s make that future a reality.
To listen to the full conversation, view the recording here.
To learn more about how this approach can be utilized by your organization, schedule a demo today.