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Payer and HIE Collaboration Relies on Trust, Experience, and Reach
By Joni Pidcock, director, Payer Products & Services, Orion Health
Timely, accurate, and unbiased information is essential to making sound decisions; from the coffee you order in the morning to the health care choices you make for yourself and your family. Quality, cost, and risk are just a few factors that are needed to be fully informed. The use of Health Savings Accounts (HSA) in the US is increasing, and consumers with their spending power are demanding to understand how their decisions can improve outcomes, lower the cost of care, and improve their experience. As the US health care industry moves towards consumer-driven health care, it is essential for payers to enhance their efforts to make this information available and easy to access.
Traditionally, payer organizations have catered to government and employer groups, which made up the majority of the purchasing power of the US population. Changes to regulations, access to HSAs and health insurance exchanges are forcing not just the industry, but consumers to take a closer look at where their health care dollars are being spent. Per member per month (PMPM) costs and revenue forecasts take on a more inclusive calculation when consumers have the ability to choose the experience and care quality.
The good news is that health information exchanges or HIEs have paved the way for payers to rapidly respond to the needs of consumer-driven health care. How? Trust, experience and reach.
Trust
Fair or not, payers have a reputation for blocking access to health care services in favor of the bottom line. This perception has contributed to delays in efforts to share data between the clinician and the insurance companies. Clinicians concerned about clinical decisions being dictated by insurance companies may have hesitations for the open sharing of patient data. The good news is that in the past year, trends are showing a movement towards increased collaboration between payers and providers. This is largely in part due to the rise in value-based contracts, accountable care, bundled payments, new ONC and CMS interoperability requirements, and a shift in expectations from consumers and employer groups.
Alternatively, HIEs are unbiased data trustees1 with the goal of providing HIPAA compliant technology products and solutions to facilitate the exchange of protected health information (PHI). Payer organizations can capitalize on the trust that HIEs have with the provider community by becoming a participant in the community exchange of information. The HIE has the real-time clinical data that payers require and, in exchange, payers can provide the financial view of the patient. Due to the lack of interoperability in health care technology, collaboration is the fastest route to obtaining that data. To provide high quality health care while also lowering the costs of providing that care and increasing patient engagement, payers need to understand the complete clinical view of the member to add important nuance to the financial view of their members and the provider needs to understand the clinical view outside of their own provider organization. Once this is accomplished, then the payer/HIE can provide consumers timely access to this information for themselves and their family.
Experience
HIEs are adept at consuming, normalizing, and packaging clinical data by member in a region. Boots on the ground experience gives them the expertise in the nuances of consuming clinical data from a variety of sources with a variety of IT products. This is the real cost of providing the most up-to-date information on the right patient at the right time and to the right person.
But the benefits aren’t only a one-way street. HIEs are looking to expand the value they provide to regional provider groups. Medical and pharmaceutical claims data from the payer can enhance the patient long record. That data is important to power population health management tools and analytics. A payer/clinical patient long record can provide additional clinical/claims data for their patient if the patient has seen providers that are associated with the payer. A payer inclusive patient long record will provide a patient record with data from all provider organizations associated with the payer. Access to this information can help provide valuable information for making clinical care decisions, for avoiding repeating costly tests and for filling in medical and pharmaceutical history that may be missed by the patient. Also, this is another step towards meeting providers where they are in their workflow by populating the HIE platform with data required to meet value-based contracts.
Reach
Payers that cover a particular geographic region could benefit from collaborating with the local regional HIE to provide claims data that would offer a regional “all payer” view for providers to access patient data. Even state-owned payer organizations cover members outside of their immediate region and payers can connect to HIEs outside of the traditional geographic area, allowing for access to members that are employed by regional employers. This would provide payers a more holistic view of clinical data for their membership.
Too many sources and technology options are a problem in the clinical and administrative office. Most provider offices and hospitals deal with multiple payers. Payer interest and integration with HIEs is definitely a growing trend as payers see the potential to reach members and access clinical data both inside and outside the payer geographic region by becoming a part of the HIE community. Payers are also realizing the value of analysis on a richer set of clinical data to enable high-value programs such as early identification of high-risk pregnancy and predicting re-admission rates. Additionally, as payers look to leverage machine learning and AI, they are realizing those tools are only as good as the data that drives the models and algorithms, and data acquisition is a lengthy and costly effort that is rife with data quality and collaboration issues. Adding the public HIEs to the payer data acquisition strategy allows the payer to benefit from the work the HIEs have already accomplished.
Right patient, Right care, Right place, Right cost
Consumer-driven health care has the same data access and quality challenges that all healthcare interoperability initiatives share. Reliable, secure and quality PHI is key to driving workflows to patients, providers and healthcare administrators. Payer organizations that focus their collaboration efforts with HIEs will be one step closer to success. HIEs are well positioned to drive innovation and to both anticipate and meet the needs of the healthcare industry, all of which are essential to creating a well-informed healthcare community and consumer base to determine the right patient, right care, right place and right cost.
Reference:
- SHIEC. (2019). HIE 101 - SHIEC. [online] Available at https://strategichie.com/resources/hie-101/#1519863086641-adb25ac0-eb35
