A glaring omission in the last blog  was a discussion of individual health in the emerging healthcare sustainability model. At a recent conference hosted by Microsoft, the group engaged in a conversation of healthcare cost and quality improvements that focused on sustaining individual health – catching individuals before they landed in the category where expensive intervention and services were needed. Past blogs and other industry articles in the past six months have discussed the tremendous opportunities for savings through promotion of health and illness avoidance - particularly for the top 5-6 chronic illnesses in the US.

Healthcare reform creates new markets, new consumers and…escalates cost pressures.  In both business and technology markets, collisions opportunities between payer and provider processes and investments abound.  The greatest synergies for consumer engagement, cost control and quality improvement likely rest with those delivery systems in which the insurance, health, wellness and clinical processes and systems are integrated and aligned. More than a few healthcare payers in recent weeks reported considering the reform era advantages of the payer-provider model.

As the national healthcare reform debate goes back to the drawing board, the spotlight is refocused on state and and regional initiatives. State and regional initiatives have been unflagging active during the national debate.  Notable recent announcements and trends in 2010 include renewed state assessments of newer architectures and applications to improve technology costs, transaction efficiency and access to information of public programs. Commercial and regional markets also reflect continued and renewed investment in health information exchanges, a resurgence of provider owned health plans and integrated delivery systems, and, yet again, renewed collaborative attempts among healthcare payers. AHIP and Blue Cross Blue Shield Association announced the extension last week of a pilot program in New Jersey, begun last fall, in which health care payers coordinate key administrative transactons in common formats through a single provider portal.

On December 18, it was reported that the Department of Health and Human Services announced plans to build a database of claims records from all healthcare payers to strengthen its analysis of healthcare trends and treatment outcomes. This initiative comes from ARRA funding to establish and promote better comparative effectiveness research.

Discussions this week on meaningful use have turned to the application of quality metrics.  A meaningful use would be the application of quality indicators to electronic health record information to determine whether physicians are adhering to care and wellness standards.  An example given by National Health IT Coordinator David Blumenthal, MD, is using metrics and measures to determine whether a physician's patients with hypertension have their blood pressure under control. And, with this announcement, we see the emerging integration of the availability of healthcare information in the electronic health record (and other data sets) with another emerging market trend:  triggers, metrics and alerts that would provide "actionable advice."

Healthcare payers arrive at the 2010 IT budget season amidst healthcare reform uncertainties, with continuing economic challenges, with seemingly battered reputations and faced with an enormous ICD-10 and HIPAA 5010 compliance commitment through 2013.  The creation of a comprehensive business and technology budget plan can be a mind numbing exercise this year.  In 2009, healthcare payers continued to indicate that the major application technology investment was core administrative (claims) solutions.  The changing market dynamics, recent technology vendor and healthcare payer announcements suggest that healthcare payers must significantly shift in technology investment priorities for 2010 and beyond

Healthcare IT markets, banks, EDI and web portal vendor markets all reported expanded revenue cycle management initiatives in recent months.  Emdeon, betting on new opportunities to leverage its transaction services into broader revenue cycle management, fraud and abuse and reporting services, extended an IPO offering in late July.  This following key acquisition announcements and a partnership with Bloodhound technologies.  A number of other technology vendors with strength in transaction processing on both the payer and provider side are also poised to move directly into or more tangentially support, revenue cycle management solutions.