It is widely known that our US health care system’s costs are at least double that of any other health system in the developed world, and while there are large pockets of brilliance and advance, it’s also understood that quality, access, and outcomes varies widely. One major difference is that we have basically two major stakeholders trying to maximize their respective outcomes – the payers and providers – and they have been at war with each other for decades with the patients often being the collateral damage. Fortunately, payment incentives and consumerism are changing that.
The gradual convergence of payers and providers and their combined expertise offers real hope (perhaps even peaceful prosperity). Better use of data and analytics will be a key and required component for success. Our recent Analytics Market Trends Report goes into depth of the many advances, challenges, and capable vendors in this space. To gain value from analytics, we will have to do a better job with, among many things, data access/governance, quality, comprehensiveness, and sharing.
While each stakeholder – payer and provider – will likely have already initiated their own analytics efforts (payers are generally a bit ahead of providers, as the Society of Actuaries pointed out), their efforts will be limited by the data they have. This data will include what information they have created themselves, and what they have requested and/or received from others. With so many patients switching providers and payers these days, any single entity’s data is likely to be lacking.
Better to Give than Receive?
Both sides are adept at making requests from the other – but neither side is particularly good at responding to requests, or proactively sending the other side something useful. Regulatory standards for transactional exchange, such as HIPAA eligibility and claims, were a huge past focus and still leave too much variability – but even if this was fixed, it would still not address the main issue of the need for cooperation.
A large amount of the battle between payers and providers involves transactional data regarding what will be covered for a particular patient. Payers may initially deny authorization or payment – or request additional detail from a provider that a procedure is necessary. Providers may become annoyed that they have to explain themselves – and may also feel that payers may not clinically appreciate what is being proposed. Providers that send too little or too much (or send it in unstructured format) aren’t doing themselves any favors by making the process more difficult for the payer, which likely will struggle with how to process it or run analytics against it.
Then there is also value in exchanging information about what has happened – a patient admission, a discharge, a prescription refill, a change in medication. But who will enable this?
Exchanges Can Only Do So Much
Regional health information organizations (RHIOs) and health information exchanges (HIEs), both public and private, have attempted to play this role, and to provide some analytic functions, but issues of who pays for the service and how much, and how accurate and complete the data is (which is not really the fault of the exchange) have been primary obstacles. Complexity of consent when each entity has its own guidelines/rules (e.g. what do about age, type of condition, opt-in or -out) is made even more complicated when crossing boundaries such as state lines. Adoption of trust frameworks such as Carequality and evolving exchange standards such as Fast Healthcare Interoperability Resources (FHIR) can help, but even the best marriage vows will not help if partners don’t really want to work with each other.
Population-based data sharing offers its own challenges. The list that payers send providers of patients who have not had a specific immunization, for example, could be even more valuable if it included additional registry information about those patients, such as which immunizations they had gotten from other providers or where else they had received care. Providers may have information about prescriptions they wrote for patients, but if the patients paid the pharmacy in cash, the payer may not be aware of it (all subject to HIPAA and patient consent, of course). It’s hard to predict and improve adherence or know if a medication is successful if you don’t know if patients have filled their prescriptions.
Shared Incentives, Evolving Consumerism
Shared data platforms will make this all (much) easier and less expensive – but only if both providers and payers agree on what data in the platform to actually share with each other. Data will still have to be cleaned up and mapped, (more automated) processes will have to be redesigned to do more than just replace paper, and there needs to be a greater focus on timeliness and actionability. Although there has been lots of discussion about who has the more cutting-edge algorithms or the best analytics platform, the desire/incentive for payers and providers to work together for mutual benefit needs to come to the forefront. Although value-based reimbursement is a key driver, it may well be consumerism that really drives this convergence, with patients being the real beneficiaries.
We hope you’ll join us for our Convergence conference in Boston, Oct 4-6 to further the discussion and gain key insights from some of the most advanced organizations.