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IDC PlanScape:指南準確度與醫療網的充足性 - 保險業者需適當處理的時刻

IDC PlanScape: Directory Accuracy and Network Adequacy - For Payers, the Time Has Come

出版商 IDC 商品編碼 357879
出版日期 內容資訊 英文 15 Pages
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IDC PlanScape:指南準確度與醫療網的充足性 - 保險業者需適當處理的時刻 IDC PlanScape: Directory Accuracy and Network Adequacy - For Payers, the Time Has Come
出版日期: 2016年05月12日 內容資訊: 英文 15 Pages

保險業者與顧客的關係起於患者是否於當地保險醫療網內部就醫、醫師是否接受初診病患、是否透過溝通進行正確適當的醫療行為。如果稍後患者表示「自己的資訊不正確、不足」、保險業者的品牌將一落千丈、保戶也會更換至其他保險公司。透過高度透明化,曾有兩家保險業者因誤導顧客醫療網資訊(其一為集團訴訟、以1500萬美元和解) 、被CMS (醫療保險、醫療補助計劃中心) 開罰25,000美元。另外各州也有新的罰金規則。最重要的是這點讓保險業者對於指南系統產生了關心。

本報告針對美國保險市場、提供提高指南正確性 (Directory Accuracy) 與醫療網充足性 (Network Adequacy) 的行動與具體方法、成本效率分析。

IDC PlanScape說明圖



  • 要求遵照義務頻繁的延伸/確認:透過特定指南與最基本的醫療網充足性
  • 全國動向
  • 透過立法與規範醫療網透明化、維持保險業者的醫療網選擇能力
  • 應對醫療網的充足改善以及指南品質檢測
  • 品牌差異:消費者契約需求
  • 準備遠距醫療/虛擬醫療、醫療網設計變更用與醫療網充足性變數變更用數據表
    • 醫療網設計變更
    • 醫療網充足性變數變更


  • 消費者透過線上/位數/平面媒體提供最新的精確情報
  • 連邦政府/州政府/業界團體遵守相關指令
  • 立法院、行政當局對醫療網充足性的提示
  • 在符合上述條件下最佳的行政成本
    • 如何提出問題?
    • 為什麼會產生問題?



  • 保險業者數據階層化:數據階層、數據品質費用政策、將指南用核心數據營業用核心數據與「可能品質良好」的數據分開
  • 適應指南、集合數據、非競爭的思考方式:數據實際上可保證競爭優勢嗎?值得單獨處理的成本嗎?
  • 活用強力數據模式、數據架構、保證個別記錄系統
  • 實踐包括 (基礎)反應可動技術、保險業者數據、維持系統



Product Code: US41242516

This IDC PlanScape offers guidance to increase the effectiveness of directory accuracy and network adequacy initiatives. "Customer engagement with payers starts day one with the patient seeing if their set of doctors is local, in-network, available for new patients, speaks their language, and is available to them conveniently. If that consumer information is later found to be inaccurate or inadequate, a payer's brand is tarnished forever and now with the increase of the individual marketplace, consumers will go elsewhere," states Jeff Rivkin, research director for Payer IT Strategies at IDC Health Insights. "High-visibility rulings have penalized over a quarter million dollars in fines to two commercial payers for 'misleading' consumers about their networks (with one resultant $15 million class-action settlement), CMS has imposed $25,000 (per beneficiary) fines for (Medicare Advantage [MA]) inaccuracies, and the newly engaged state legislatures threaten new mandates and fines. Most importantly, the new consumer engagement paradigms are driving payers to finally pay attention to the directory ecosystem."

IDC PlanScape Figure

Executive Summary

Why Is Directory Accuracy and Network Adequacy Important?

  • Mandated Compliance Demanding Frequent Outreach/Validation: With Specific Mandatory Directory Fields and Minimum Network Adequacy Requirements
  • Address the National Tide
  • Retain the Payer's Ability to Narrow Networks by Being Transparent with Network Adequacy to Legislators and Regulators
  • Be Ready for Increased Network Adequacy and Directory Quality Audits
  • Differentiate the Brand: Address Consumer Engagement Desires
  • Set the Table for Telemedicine/Virtual Care Network Design Alternatives and Changes to Network Adequacy Variables
    • Network Design Changing
    • Network Adequacy Variables Changing

What Is Directory Accuracy and Network Adequacy?

  • Provide Current, Accurate Online, Electronic, and Paper Directories to Consumers
  • Comply with Federal, State, and Industry Mandates in This Area
  • Demonstrate Network Adequacy to Legislators and Regulators
  • Optimize Administrative Cost Addressing These Requirements
    • How Bad Is the Problem?
    • Why Is There a Problem?

Who Are the Key Stakeholders?

How Can My Organization Take Advantage of Directory Accuracy and Network Adequacy?

  • Tier the Provider Data: Determine Data Tiers and the Costs of Data Quality, Separate Core Directory Data from Core Operational Data and from Quality-Would-Be-Nice-to-Have Data
  • For the Directory Data, Adopt a Collective Noncompetitive Mindset: Is This Data Really a Competitive Advantage? Is It Worth the Cost of Doing It Alone?
  • Use a Strong Data Model and Data Architecture Ensuring One System of Record
  • Execute a Comprehensive Baseline, Reactive, and Proactive Approach to Maintaining the Provider Data Ecosystem

Essential Guidance

Related Research

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