Improving patient outcomes while curbing healthcare costs remains a shared imperative for both payers and providers. Yet achieving this balance requires more than isolated initiatives — it calls for systemic strategies that bring care coordination, quality measurement and population health management together.
For payers, this means advancing efforts to close care gaps and design performance measures that meaningfully impact patient health. Success, however, hinges on a critical enabler: comprehensive, integrated patient data. When claims and clinical information are unified, payers gain the insight needed to align care delivery with strategic goals.
To explore how next-generation data platforms are making this possible, Becker’s Healthcare spoke with Mike O’Neill, CEO of MedicaSoft.
How data unlocks efficiency + efficacy
Payers have rich repositories of claims information. While claims data reveals what care was ordered for patients, clinical data sheds light on why that care was ordered and the outcomes achieved.
Integrating clinical and claims data gives payers and providers a more complete, end-to-end picture of patients’ health. This opens the door to a wide array of benefits.
“By consolidating [claims and clinical] data, payers can make information available for a full set of use cases that hopefully lead to higher-quality decisions and greater cost efficiency,” Mr. O’Neill explained.
For example, access to comprehensive data supports evidence-based care that is tailored to patient needs. It can also guide patients to appropriate screenings that will be beneficial for their long-term health. By combining and analyzing both clinical and claims data, payers can identify and reduce duplicative tests and services that are burdensome for patients and costly for the healthcare sector.
In addition, complete clinical data supports the level of payer-provider collaboration that is essential for value-based care. At its core, value-based care is all about data-driven performance. This requires a common language based on metrics and evaluations.
“The more complete the data picture is between payers and providers, the better the data-driven alignment will be,” Mr. O’Neill said. “Integrated data helps align the two communities in terms of outcomes and controlling costs.”
Key challenges in data unification
While payers have extensive experience with claims data, they’re often less familiar with clinical data. One of the biggest obstacles to integrating these different types of information is linking clinical and claims data for each patient. It’s easy to associate claims information with patients using member IDs; however, that type of common identifier doesn’t exist for clinical data.
Ensuring that data is free from duplicates is another hurdle. Mr. O’Neill explained that different use cases demand access to different types of data. Calculating quality measures, for example, requires a different data set than care coordination or case management. A natural result is that many organizations end up creating multiple data silos, rather than one unified view of patient information.
“For each use case, organizations may build a separate database,” he said. “This creates silos in which multiple copies of data exist in different places. Information then becomes stale over time.”
How to harness information for better decision-making
A platform-based approach to claims and clinical data allows payers to match patient information, improve data quality, aggregate insights for diverse use cases and establish a robust enterprise architecture.
“A unified data platform like MedicaSoft empowers payers to use data in compliant ways across the full spectrum of use cases, from care delivery to analytics and population health,” Mr. O’Neill said. “We help payers bring all the data they need together in one place — that helps the entire healthcare ecosystem.”
By unifying data, organizations eliminate inefficiencies and avoid building new databases for every new initiative. Just as importantly, integrated platforms lay the groundwork for AI-enabled workflows that can further advance efficiency and insight.
Interoperability has become one of healthcare’s defining imperatives. As payers and providers align around value-based and patient-centered care, seamless information exchange is no longer optional; it is foundational. While standards for interoperability exist, true progress depends on translating them into practice through secure, timely and effective data sharing.
“There’s tremendous value in centralizing patient data in a platform and there’s even more value in sharing information with others,” Mr. O’Neill said. “If you think about data from a platform point of view up front, it will pay dividends down the road as you integrate clinical and claims data.”
