I attended the Operations and Technology Forum, sponsored by America’s Health Insurance Plans (AHIP), in Chicago last month.

While targeted at health plans and insurers, the content may hold some lessons for healthcare delivery organizations as they take on more financial risk, operating under reimbursement methodologies that necessitate they think more like payers.

Three themes emerged from the slate of speakers featuring health plans, IT vendors and industry experts:

1. The challenges in launching health insurance exchanges (HIX),

2. The importance of analytics to understand the risk within the populations for which organizations are accountable, and

3. The role of cost and quality transparency in driving patient/consumer behavior.

Challenges Launching Health Insurance Exchanges

The well-publicized problems with healthcare.gov and some state websites represent the first of three issues—“scandals” according to one analyst—with the launching of Obamacare. The second is the revelation that many individuals, despite assurances to the contrary, will lose their current health coverage and will need to select benefits from an exchange. The third expected issue is that many beneficiaries, again with assurances to the contrary, will not be able to remain with their current healthcare provider. This is because payers will employ narrower networks of providers, based on cost and quality metrics.

Growing Importance of Analytics for Understanding and Managing Risk

Analytics will occupy an increasingly important role in healthcare organizations. As they look to better manage clinical and financial risk, payers and providers will use analytics to identify at-risk patients/members and stratify them within populations in order to guide the allocation of resources. This includes projects such as identifying the hospitalization risk for chronic disease populations and the inherent risk of re-hospitalizations or readmissions. As care is delivered at the individual level, analytics will need to provide both the “macro view” of population and the “micro view” of patients that make up the population. Analytics will also increase the understanding of provider behavior; for example, measuring provider compliance with evidence-based guidelines as a means of managing clinical and financial risk.

Cost and Quality Transparency Influencing Patient and Consumer Behavior

The continuing rise in healthcare costs has led to increased financial responsibility for consumers and increased expectations of patients to make prudent healthcare decisions based on quality and cost. To promote this behavior, payers and providers are beginning to share this information with greater transparency. This is important, because cost variation of a given service—even within a single health plan and geography—reportedly can reach 7x. Furthermore, consumers are often unable to distinguish between needed and unneeded care and, as with other industries, typically equate higher cost with higher quality. Changing patient behavior won’t be easy, however. Thomas Goetz, author of “The Decision Tree: Taking Control of Your Health in the New Era of Personalized Medicine” claims that helping consumers make better decisions—at scale—is “the hardest problem in healthcare.”

As healthcare delivery organizations rely more heavily on value-based reimbursement and are rewarded for managing utilization, relationships with payers, risk analytics and patient engagement will take on increased importance. This has the potential for a significant impact in a competitive market of narrow provider networks as consumers are incented to look more closely at their healthcare decisions.