Our perspective: Insights-driven health outcomes

Perspective: Insights-driven outcomes | By: Carelon

The volume of data available to health plans today is greater than ever before. But data alone cannot improve clinical outcomes; insights-powered decision-making can, though. And leading health plans are using advanced measures, like predicting modeling and machine learning, to make that the standard practice across the healthcare system.

Medical knowledge doubles about every 73 days. That makes it an exciting, yet challenging time to be in healthcare.Clearly, it’s never been more important to stay ahead of the curve. 

Health tech firms, pharma companies, and medical researchers are all quickly advancing innovations across the industry. For instance, the number of new drugs and treatments approved each year has roughly doubled from a decade ago.2 But not all innovations create meaningful benefits. Knowing where risks outweigh advantages is key. 

Physicians also play a significant role in expanding the body of medical knowledge by documenting the care they provide in patient charts and EMRs, payer platforms, and other tools. But their contributions can come at a price: in 2021, doctors spent an average of 15.5 hours on administrative tasks each week—a number that has increased dramatically over the last five years.3 Clinicians, therefore, face a formidable challenge—keeping their medical knowledge current while keeping up with administrative requirements.    

With so many different sources of medical information, we need a way to harness it and ultimately, provide better care and better experiences.


Our perspective: research and data hold the keys to health outcomes


How health plans are making a difference

The data available to health plans is expansive and includes medical and pharmacy claims, provider behavior trends, FDA drug and medical device approvals, information about breaking medical research, and more. To empower better care, plans can connect and analyze data through next-generation tools and teams with expertise in both medical and data science. Health plans can better support clinicians by combining clinical knowledge with available data and technology to create a high-tech, high-touch ecosystem. Here’s how they’re turning information into insights, and insights into action:

Automating clinical pathways to inform care

Plans are leveraging advances in medical science to create clinical pathways that align care with the latest best practices. Built by teams who monitor and analyze breaking medical developments, clinical pathways help guide providers to care supported by medical evidence and protect members from care that isn’t. Physicians with backgrounds, certifications, and real-world experience in specialized fields such as oncology, cardiology, and surgery ensure clinical pathway quality, accuracy, and relevance.

The latest generation of clinical pathways focus beyond the management of isolated tests or treatments, and include programs to manage entire cancer treatment regimens, pervasive conditions such as back pain, and episodes of post-acute care for members transitioning from the hospital to home.

Creating new insights through research

Plans are also creating the medical evidence of the future through partnerships with life sciences companies, providers, and other stakeholders across the ecosystem. Highly experienced teams of researchers and clinicians design studies and leverage an extensive pool of clinical and claims data to:

  • Generate evidence of the value of biomedical products
  • Uncover vital evidence on the utilization, safety, and effectiveness of biopharmaceuticals and devices in large patient populations
  • Conduct clinical trials and registries–from small studies focused on rare and orphan diseases to large studies of complex and chronic conditions
  • Engage patients in research to make therapies and programs more real-world-ready and relevant

Plans also keep ahead of pharmaceutical trends by monitoring, analyzing, and reporting on upcoming Food and Drug Administration (FDA) approvals for drugs and biologics, as well as new molecular entities, formulations, and indications. They use this data to generate insights fuel initiatives to manage care and costs through innovative clinical, operational, and network management strategies.

Leveraging data and technology to pinpoint care

Plans are using large and ever-expanding bodies of data drawn from claims, financial, clinical, community and consumer databases and other sources to power AI tools, predictive models, and insights. For example, they’re harnessing technologies like AI and machine learning (ML) to pave the way for precision medicine, where treatments can be customized to specific individuals, tailored to factors such as age, gender, family history, immune profile, metabolic profile, and environment vulnerability.4

Forward-thinking health plans are creating and applying advancements in both medical and data science to usher in a new era of improved health outcomes. By harnessing data-driven insights, plans are creating digital-first solutions that promote personalized, proactive, and precise interactions, making the healthcare system more effective and efficient for everyone.


Staying ahead of the curve, improving experiences


Forward-thinking health plans can create and apply advancements in both medical and data science to usher in a new era of personalized care and improved health outcomes. By harnessing data-driven insights, plans can create digital-first solutions that promote personalized, proactive, and precise interactions, making the healthcare system more effective and efficient for all stakeholders.


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  1. National Library of Medicine, National Center for Biotechnology Information, Challenges and Opportunities Facing Medical Education (accessed May 2022): ncbi.nlm.nih.gov/pmc/articles/PMC3116346 .
  2. Congressional Budget office, Research and Development in the Pharmaceutical Industry (accessed May 2022): nature.com .
  3. Annals of Internal Medicine, Physician Time Spent Using the Electronic Health Record During Outpatient Encounters (accessed May 2022): news.gallup.com .
  4. National Institutes of Health, National Library of Medicine, The rise of artificial intelligence in healthcare applications (accessed June 2022): ncbi.nlm.nih.gov/pmc/articles/PMC7325854/ .

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