GHIT Digital POV: Bridging the Data Divide Between Payers and Providers
GHIT Digital POV: Bridging the Data Divide Between Payers and Providers
By GHIT Digital
Introduction
The U.S. healthcare ecosystem is at a crossroads. Payers and providers are under immense pressure from regulatory reform, rising costs, and the accelerating shift toward value-based care (VBC). Yet one persistent challenge continues to undermine transformation: the inability to integrate claims, clinical, pharmacy, and social determinants of health (SDOH) data into a unified, actionable foundation.
While many payers have invested in data sharing capabilities, true integration remains elusive. This gap prevents the industry from realizing the full potential of AI, automation, and predictive analytics to drive population health outcomes, operational efficiency, and member satisfaction.
The Current Landscape: Sharing ≠ Integration
Recent research reveals the paradox:
- - 66% of payers are strong at data sharing.
- - Only 57% succeed in integrating external data.
- - 85% lack a centralized data platform.
This is more than a technical gap; it is a structural misalignment between payers and providers.
- - Payers focus on financial risk adjustment, premium billing, claims adjudication, star ratings, and regulatory compliance.
- - Providers focus on clinical workflows, care coordination, specialty treatment episodes, and population health management.
Without integration, the insights remain fragmented—limiting both operational efficiency and patient outcomes.
Building the Foundation: Member 360 as the New Clinical Record
For providers, the Electronic Health Record (EHR) is the system of truth. For payers, the equivalent must be a Member 360 profile that integrates:
- - Claims data: utilization, costs, diagnoses, procedures.
- - Clinical data: labs, vitals, imaging, physician notes.
- - Pharmacy data: fills, no-fills, adherence, PBM interactions.
- - SDOH factors: housing stability, food access, transportation.
- - Episode-of-care journeys: chronic disease cycles, surgical pathways, oncology treatments.
This holistic, longitudinal record enables risk stratification, predictive modeling, and personalized member engagement at scale.
Unlocking AI and Analytics for Payers
AI adoption across payers is still below 20%, largely due to incomplete data foundations. But once integration is achieved, AI-first operations become possible.
Key AI-Driven Use Cases
- 1. Prior Authorization Automation
- Automates document review, reducing turnaround times.
- Uses predictive models to evaluate medical necessity.
- Aligned with CMS mandates on prior auth modernization.
- 2. Risk Adjustment & Coding Accuracy
- Identifies gaps in HCC (Hierarchical Condition Categories).
- Improves Medicare Advantage star ratings and compliance.
- Predicts disease progression by merging clinical + claims + SDOH.
- 3. Pharmacy Insights & Adherence
- Flags abandoned prescriptions at retail pharmacies.
- Predicts medication non-adherence, enabling outreach.
- Optimizes PBM collaboration for better outcomes.
- 4. Population Health & Care Gaps
- Detects high-risk members through episodes of care (e.g., heart failure, diabetes).
- Proactive interventions reduce ER visits and readmissions.
- Guides site-of-care optimization (urgent care vs. ED).
- 5. Fraud, Waste, and Abuse (FWA)
- Detects anomalies in claims submissions.
- Identifies duplicate billing, upcoding, and provider misuse.
Payer–Provider Collaboration: From Adversarial to Aligned
Historically, payers and providers have had adversarial relationships—contract negotiations, reimbursement disputes, and data silos. But under delegated risk, capitation, and VBC contracts, collaboration is no longer optional.
Collaborative Use Cases
- - Shared Care Planning: Unified data informs holistic care plans.
- - Real-Time Alerts: Payers notify providers of admissions, discharges, or prescription gaps.
- - Utilization Optimization: Joint analysis of episode-of-care costs and outcomes.
- - Value-Based Contracting: Transparent, data-driven reimbursement models.
When both sides align, the result is a win–win: lower costs, improved outcomes, and sustainable margins.
Workflow: From Fragmentation to Integration
- 1. Step 1: Data Sources
- Claims, Clinical, Pharmacy, SDOH, Episode-of-Care
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- 2. Step 2: Centralized Data Platform
- Enterprise Data Management (EDM)
- Interoperability (FHIR, HL7, APIs)
- Data normalization & governance
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- 3. Step 3: Advanced Analytics & AI
- Risk Adjustment & Stars Optimization
- Prior Auth Automation
- Population Health Insights
- Fraud & Abuse Detection
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- 4. Step 4: Provider Collaboration
- Shared Member 360 Views
- Real-Time Alerts (ADT, Rx no-fill)
- VBC Data Sharing
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- 5. Step 5: Outcomes
- Lower cost of care
- Higher quality scores
- Better member experience
- Improved health outcomes
GHIT Digital Perspective
At GHIT Digital, we believe that data integration is the foundation of payer transformation. Our team helps payers and providers:
- - Implement low-code platforms like NewgenONE across ECM, BPM, CCM.
- - Build centralized, scalable member 360 repositories.
- - Deploy AI-first workflows for claims repair, prior auth, and care gap closure.
- - Support delegated risk models with advanced analytics.
- - Enable real-time payer–provider collaboration through interoperability.
The future belongs to payers who can transform fragmented data into integrated insights, and then into member-centric, outcome-driven actions.
Conclusion
The payer–provider relationship is shifting from transactional to transformational. By investing in centralized data platforms, AI-driven workflows, and real-time collaboration, healthcare organizations can bridge the divide between financial management and clinical excellence.
In doing so, they unlock the promise of value-based care, population health management, and sustainable healthcare economics.
Hashtags | Key Words
#Healthcare #Payers #Providers #ValueBasedCare #AIinHealthcare #HealthcareData #Interoperability #PopulationHealth #CareManagement #PharmacyAnalytics #RiskAdjustment #PriorAuthorization #FraudDetection #HealthcareInnovation #GHITDigital
We should connect. We could talk about market trends and explore business synergies, if any.
Monika Vashishtha, MBA, ITIL, PMP
President & COO
https://ghit.digital I +1 201.792.8924
