How data can help payers

by Dan Kotok

How many non-medical personal attributes do you think it takes to predict a person’s medical costs? 75? 150? Try 442. In the healthcare industry, payers are using data to make their jobs—and the consumer’s healthcare experience—easier. With data, payers can help create better health outcomes, be involved in total care management, and provide price transparency.

In part one of this series, we covered the overall scope of big data in healthcare. Now, we’re showing you exactly how payers in healthcare can leverage big data.


Better health outcomes

I know what you’re thinking: “How can payers use data to create better health outcomes? They’re only involved in the business side of things!” But the interaction between the payer and the provider is so close that payers really can make a huge difference in the health outcomes that patients experience.

For example, Bright Health, an integrated health insurance startup, is building a data infrastructure that “has the potential to produce better health outcomes for millions of hardworking Americans.” They’re using data to help the payer model become more consumer-centric. They recently raised $200 million in funds, evidence that their model is working.

Another insurance company rebuilding their data infrastructure is Oscar Health. They’re using data to help them prune doctors from their network, leaving consumers with fewer but higher quality choices. They’re also using data to help consumers better understand the care they’re getting.

“As [an] insurance company, we already have a lot more data than anybody else in the system,” said Mario Schlosser, CEO of Oscar Health. “Most partners and vendors in health care—the big drug vendors, the big imaging vendors, and so on—are not set up for anything close to real-time data transmission. . . . Seeing what is happening with somebody in real-time has one of the biggest possible impacts on whether that person would be willing to take advice and think differently about their care.”

As payers and consumers use data, they can make smarter decisions and improve consumers’ health outcomes.


Total care management

Data is helping payers create a better consumer experience at a lower cost. How? By moving towards total care management, “an engagement model for how support teams can engage and manage [consumer] relationships across the complex combination of hospital systems.”

While we may think of data as being impersonal, it actually helps payers make the healthcare experience more personal for consumers.

According to Health Data Management, “Information technology will undergird payer efforts to migrate from pure claims administration and payment to burgeoning initiatives that help insurers offer care management and health optimization for those who they cover.” In other words, instead of just paying for a patient’s healthcare, payers can use data to make the entire experience more efficient and pleasant for consumers.


Price transparency

With CMS’s new requirement that hospitals post a list of their standard charges on the internet, it’s clear that price transparency is important to consumers.

Bind, an on-demand health insurance company, is using data to enable broad price transparency. Working with UnitedHealthcare and using data analytics resources, Bind accesses and analyzes episodic costs, quality measures, and other financial data to tell consumers exactly what procedures will cost and how much consumers will need to pay.

“For the first time, the state of data science and analytics is allowing us to make sense of the vast wealth of provider, clinical, and treatment data that’s out there,” said Trevor Fast, Plan Design Lead at Bind. “The insurance company is the only place where all that data comes together. The payer is the only one that can look out on all of the different providers and tell the patient about the pricing of every one of them. We can deliver that data to consumers in a clear, accessible way through the supercomputers most Americans have in their pockets.”

Right on their smartphones, consumers can view

  • How much a service will cost at a retail clinic versus in the emergency room
  • Paycheck deductions for selected services
  • Out-of-pocket costs for selected services

When payers have access to this data, they can share it with consumers so everyone is fully aware of the costs involved in healthcare.


By using data, payers are creating better health outcomes, moving towards total care management, and providing price transparency for consumers. While payers do their work largely behind the scenes, data is bringing them closer to the forefront of the streamlined consumer experience.

In part three of this blog series, I take a look at the specific ways that big data can be beneficial to healthcare providers.


Dan-KotokDan is a Senior Account Executive here at Simplus. He has specialties in, training user and system testing cycles, end user and support training, business process mapping, LSS project management, implementations, and change management.

[email protected]

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