So many digital startups have entered the market over the past decade that providers have become burnt out due to the noise caused by an overabundance of “point solutions.” But healthcare is complex for many reasons—fragmentation and misaligned incentives being two important ones. That’s why healthcare is now inundated with new products and services that don’t connect seamlessly with each other and may make fragmentation worse.
Seth Joseph, Summit Health founder and managing director, and frequent Forbes contributor, explains, “The challenge is no longer building software or apps for individuals. The opportunity now lies in connecting those individuals, and their systems, to facilitate new or more efficient interactions.”
In a recent Avaneer Health podcast, The Spark, Joseph suggests that what healthcare really needs is a way to better align constituents who have different priorities and incentives. “We need to build businesses that create value for solving two-sided problems where you can align incentives and deliver value on both sides.”
One of the best examples of misaligned incentives in healthcare is the complex exchange of data between payers and providers. Coverage verification is an excellent example. Individuals typically change employers or health plans, or have multiple lapses in coverage, several times throughout their lives. Even if they don’t change carriers, they may still experience benefit or network changes within their existing plans during annual open enrollment periods. It’s a problem that research shows can lead to hundreds of billions of dollars in administrative waste each year.
The problem is that capturing and sharing updated coverage information has become extremely difficult for both payers and providers due to a lack of transparency and interoperability between their systems. For payers, this means they can miss secondary and tertiary coverage, causing them to pay for services that should have been covered by other plans. For providers, it means denied claims. In fact, incorrect or missing coverage information is one of the top causes of denied claims. Inaccurate data can also lead to delays in care or cause patients to have to pay for services that were covered.
This lack of transparency fuels friction and distrust. The good news is that platforms and networks have the ability to alleviate challenges like this by driving a new kind of innovation that aligns incentives and fuels transparency and trust.
In his recent Forbes article, Into the Death Zone? What Digital Health Can Learn From Epic’s $3.8B Revenue, Joseph says, “Platform businesses create value by bringing different constituents together and facilitating an exchange of value between them, not by selling software to either side.” He believes this is why innovative companies like Slack, Airbnb, and Uber have been so successful. They’ve leveraged platforms and networks to “drive growth, defensibility, and profitability.” They didn’t reinvent collaboration, travel, and vacationing; they just made those activities easier and more efficient, adding value to existing industries in a way that was mutually beneficial for all constituents. In the case of Airbnb, it added value for the homeowner and the consumer, not just for Airbnb.
Today, payers and providers have access to a new platform-based network that solves the issues of misaligned incentives and interoperability challenges. Avaneer Coverage Direct™ is the newest solution available on the Avaneer Network™, a digital network and platform that simplifies the business of healthcare. Designed as a modern IT infrastructure for sharing healthcare data, Avaneer Coverage Direct enables payers and providers to connect directly to facilitate timely, updated insight into patient/member coverage information without the need to aggregate data or send it to third parties outside the network.
Each payer and provider participating in the Avaneer Network receives a SparkZone™, which is their home base on the network. Once a participant loads their coverage information for their members/patients into their SparkZone, the Avaneer Coverage Direct process begins:
One of the most significant benefits of Avaneer Coverage Direct is that it is purpose-built and use-case specific, bringing value for both payers and providers while improving transparency for greater trust and more aligned incentives.
Research shows that digital healthcare platform companies “grow faster, are more scalable, and more profitable than their software-only counterparts.” Creating more bolt-on technologies and software—no matter how innovative—can’t fix misaligned incentives or interoperability woes.
Avaneer Coverage Direct isn’t just another software solution designed to be added on top of existing systems. It’s a new way of conducting business that leverages a digital platform and network to address specific use cases and drive mutually beneficial, aligned incentives for payers and providers alike.
