Claims Data is NOT a Trojan Horse

Probably the most notable development apparent at HIMSS14 was how much HIE and interoperability vendors are now talking about including claims data in their solution sets. Last year at this time, most of these vendors questioned the clinical value and utility of claims data at the point of care. In contrast, this year HIE vendors are now talking as if claims data were as liquid as orders and results between provider organizations. This is a positive, if somewhat overstated, development on the part of the vendors.

In mid-2013 we did see quite an uptick in interest on the part of payers to become more directly involved in HIE initiatives. This interest continued to accelerate through the remainder of 2013 as payers felt that they did have valuable information to contribute, such as eligibility checks when patient is being admitted to ER or information on patient follow-up post discharge and prescription refills (medication compliance). Some of this information, e.g. eligibility check can be provided in near real-time to a patient’s primary care physician.

While vendor support for claims data exchange points to the general increasing level of support for the evolution to value-based reimbursement (VBR), the problem with claims from the provider perspective is history.

Payers until now have been the gatekeepers-to-money translating in the minds of doctors, nurses and patients as gatekeepers-to-care. Payers have wanted better access to clinical data for decades but provider organizations do not want payers poking around in their clinical data. This is not the opinion of most providers, it is still the opinion of every provider we’ve spoken to. This stems from simple distrust of payer motives and the fear of ultimately having their data used against them, which regrettably has happened in the past.

Another challenge has been payers unwillingness to share data outside of a specific VBR contract. In numerous calls we have had with clinical executives, a common refrain has been that payers hold-out on sharing data unless there is something in it for them. Not exactly altruistic or in the best interests of providing quality care across a community.

Most provider organizations are only too happy to get specific about the limitations of claims data and further entanglements with payers through claims or other kinds of data:

Claims data is not that current
Most of the provider organizations we talk to maintain that the payers can only provide accurate data for things that happened six months ago. Anything of a shorter time horizon than that is subject to revision and therefore of very limited value. The exception to this is the aforementioned eligibility checks wherein a provider organization can receive near real-time visibility into network leakage.

Claims data is hard to work with
Providers correctly point out that most payer data sits in 1960s- and 1970s-era mainframe databases and file systems and is processed nightly by COBOL batch applications. While payers use this data to send lots of paper reports to providers, few providers have figured out how to use this data to improve patient care. Instead, this kind of payer data mostly just adds to the fog of data surrounding patient care and is by and large ignored.

Payers motives are suspect
Payers like to create the impression that they make healthcare happen for patients even though they do not provide the full suite of healthcare services nor do they appear to serve patients/members in a manner to truly help them with their healthcare issues. On this point, members share provider views and have strong distrust of payer motives.

Challenges Using Payer Data
Provider organizations will have challenges using claims data in the here and now. Looked at from what happens at the point of care, providing physicians with tools that somehow integrate financial relevance into the practice of delivering quality care is not something that most organizations are really prepared to do. From a more narrow technical perspective, the EHR’s ability to accept this data and make it relevant and actionable for front-line clinicians in their workflows is also something that providers (and by extension their HIE and EHR vendors) will need to address.

Benefits to Providers
But VBR is coming and payers are in a position to help solve some of the soon-to-be or already vexing problems for many provider organizations: revenue leakage, patient risk scoring, care gap identification, medications adherence, clinician performance management, care management or population health.

Solutions to these problems will provide a range of different benefits to provider organizations but genuinely hard to incorporate gracefully into clinician workflows. In addition, solving these problems will require more than just the payer claims data. A range of payer-derived data types will be needed to help provider organizations.

Changing Dynamics of the Payer-Provider Relationship
The use of payer-derived data is inevitable and providers need to look at potential silver lining. Some providers are actively talking about using payer data to evaluate and compare health plan benefit design. The thinking is that by comparing similarly situated patients from different payers from an outcomes standpoint, they may be able to link specific features of a benefit plan (e.g. free annual physical exam by PCP) to better outcomes. If the outcome variance from payer to payer is not minimal then maybe there is a member-benefit design problem that they need to raise with the payer. More importantly, it might put the provider in a better position to recommend to their patients the most effective health plan based on the patients’ overall health history. Using the same logic, providers could compare the performance of partner provider organizations as an aide to negotiation with those partners.

The point is that provider organizations need not view the use of payer-provided claims and other data as all downside. Claims data is as good a place as any to start building trust between traditional adversaries.