Payer Provider Data Sharing – A New World?

Providers sharing data with payers has been anxiety-provoking and is often only as part of rework for appeals of denials of payment or prior authorization. Obviously, providers have been concerned that any data they give to payers would be used to lower their revenues from that payer. Payers sharing data on patients with providers was even more unusual, with the first big information flow in that direction being CMS providing ACOs with data on their covered patients.

Today the payer-provider data landscape is changing. At-risk programs and shared savings programs have always provided some incentives, and the scale and scope of provider-payer data sharing incentives is increasing. However, the overall economic inefficiency of the US healthcare system as well as the ongoing problematic perceptions of the value of Medicare Advantage plans are setting the stage for greater expectations of health plan and provider performance. Proposed health plan reporting requirements for prior authorization approvals and denials, increasingly broad quality measurements for providers, and payer and provider price transparency are fueling the need for both payers and providers to offer better value. Not surprisingly, in our big data world the more comprehensive the data view of the patient the better.

Longstanding Data Silos

Historically providers have worked with only the data in their EHR and payers have had to impute clinical care patterns based solely on the narrow window of claims data. Transformative healthcare with increasing emphasis on prevention requires longitudinal data over the years, often over many provider and payer transitions. Knowing how long someone has had hypertension, which medications have been prescribed and whether they worked, and where and when patients have received care are the bedrock data for high-performance care.

Integrated lifetime prevention and care requires both payers and providers to have a richer and more continuous dialogue with the patient. Care based on the providing of and payment for episodic visits is simply not a modern way to create health. The question becomes how to achieve this and how to make it happen.

Laying the Groundwork

The good news is that we finally have the technology to provide this continuous dialogue with the patient. First, almost everyone has a cell phone – an extraordinary continuously available computing platform. Secondly, with modern electronic health records we now have enough digitalization of the medical parts of patient care. Finally, we have the modern data standard to support these ongoing dialogues. That data standard is FHIR (Fast Healthcare Interoperability Resources) and it allows almost all of the relevant parts of patient care to be elegantly represented in software. FHIR is in fact the very same JSON (JavaScript Object Notation) standard that supports almost every conversation between Smartphone apps and the backend server that feeds the app streams such as music, weather, or flight information; FHIR is just JSON customized for healthcare. Cloud computing makes smarter, real-time combinations of data streams possible.

We are so close to having our healthcare experiences more digitally enabled and available on our phones. So why aren’t we there yet? Obviously most purchasing of healthcare is made not by patients or consumers but by third parties such as payers and the Federal Government. These payers have historically made choices skewed to short-term horizons and acute care rather than lifetime prevention and wellness. Though we use our phones and the internet to optimize convenience, savings and value, these are not yet core goals in US healthcare.

Entering the Digital Age

On a hopeful note, the industry is moving in the right direction. Congress has made it absolutely clear that it wants the path to consumer-controlled computing in healthcare available with modern application programming interfaces and the requirement for providers to share data. Payers are being required to share data including for such contentious issues as prior authorization. There are more pieces that are starting to fall into place, notably provider and payer price transparency and publicly available digital quality performance. This transparency will power more value-based contracting. Potential legislation banning the “all or nothing” contracts which underpin much oligopoly behavior in healthcare delivery today may also be a forcing function to get payers and providers more engaged in digital conversation. These conversations happen continuously in every other industrial supply chain and could be used to model future payer and provider interactions as well. Patients are starting to use health apps, for example to capture blood pressure results directly from the BP cuff and to control insulin pumps. With this groundwork laid, and the demand greater than ever, payers and providers have the opportunity to digitally enable the resulting health improvements.

No industry has successfully resisted the digital economy. Retail, entertainment, news, travel, banking, and transportation have all tried to resist but ultimately consumers chose Amazon, Uber, and thousands of other apps to be a big part of our lives. Digitalization will force health insurers and providers to collaborate to make US healthcare more responsive and digital.

Article published in HealthIT Answers

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