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Managed Care Organizations Need Critical Data to Thrive

Public & Private Payers

Introduction

National health spending in the United States is projected to grow at an average rate of 5.5 percent per year from 2017 through 2026, reaching $5.7 trillion by 2026. While rising prices of medical goods and services and greater disposable personal income are partially to blame, increasing Medicaid costs are also a leading contributor.

As of July 2018, 34 states adopted a Medicaid Expansion program to bring new healthcare coverage options to low-income families. In response to this increase in Medicaid enrollment - and the correlated increase in costs that comes with it - states have continued to express interest in contracting with managed care organizations (MCOs) to help them deliver healthcare services to Medicaid beneficiaries.

Partnering with Providers on Clinical and Financial Health of Members

Arrangements between MCOs and states are increasingly risk-based, as MCOs control healthcare spending by trying to improve health plan performance, care quality, and overall outcomes. While the specific initiatives implemented by individual states under these contracts vary, the overall goals of MCOs are universal: Reduce unnecessary use of services and costs, focus on preventive care and early intervention, and provide quality care coordination and care management.

The push toward value-based care has amplified the need to achieve these goals, with MCOs looking to better understand the patient holistically: clinical, behavioral, social, and financial factors can all inform health and care. Traditionally, MCOs have worked solely with claims information, or the billable interactions between insured patients and a healthcare delivery system, to aid their strategies. Now, MCOs must expand their view, and overall understanding, of the patient by taking advantage of the clinical information residing in the patient health record.

Sumber Daya Terkait

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Forrester Research
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BLOOR Research Opinion Article
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HIMSSCast
How to get the most benefit from machine learning and AI How can healthcare organizations best leverage artificial intelligence (AI) tools, including generative artificial intelligence (GenAI)? Join Alex MacLeod, Director of Healthcare Solution Innovation at InterSystems, as she discusses key steps and challenges for organizations interested in adopting AI and other advanced technologies, as well as use cases that can improve care delivery and drive operational efficiencies.
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A Benchmarking System to Spark Companies to Action
Download the Report
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Get Your Data AI-Ready and Simplify Development and Deployment
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30 September, 2024
Video Overview
InterSystems OMOP is a cloud-based software-as-a-service designed to streamline healthcare research by automating the integration and transformation of clinical data into the OMOP format. This solution simplifies the creation of research data repositories and ensures easy data ingestion, transformation, and secure storage, accelerating the discovery of actionable insights and innovations in healthcare.
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A CHIME Thought Leadership Roundtable
At a CHiME Roundtable, executives from leading HCOs came together to discuss how artificial intelligence revolutionize clinical care.
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Digital Health Insights
Secure and clean FHIR data can help providers produce valuable insights to improve population health outcomes and personalized care.
06 April, 2024
A CHIME Thought Leadership Roundtable
At a CHiME Roundtable, executives from leading HCOs came together to discuss how they are addressing the shift to consumerism and creating digital experiences that meet – and exceed – rising expectations.

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