Health Plans and Physicians Need Each Other and Each Other's Patient Data

August 30, 2016
Kevin Rill, Head of Solutions Architecture, Geneia


More than ever before, the goals and outcomes of health plans and physicians are inextricably linked. For many consumers, physicians and those working in physician offices are the face of the health plan. This is even more so now with narrow networks and accountable care organizations (ACOs)– both of which have become more prevalent in the years since the Affordable Care Act was enacted and since health plans have begun actively selecting their physician networks.

Most health plans and physicians have accepted the need to transition to value-based contracts. Nearly all health plans, according to the survey conducted for the Deloitte 2015 Study of Medicare Advantage Health Plans and Providers, have some type of value-based arrangements in place:

  • 72 percent of health plans are participating in one or more patient-centered medical homes for their commercial population,
  • 62 percent are participating in ACOs with shared savings,
  • 45 percent are participating in ACOs with shared risk arrangements,
  • 45 percent use global capitation payment strategies, and
  • 41 percent use bundled payment strategies.

These value-based contracts between health plans and physicians fundamentally change the way they work together.

Historically, physicians were paid a negotiated rate for each service performed. Now, physicians typically work within a budget and receive greater financial rewards when they achieve or exceed quality and cost metrics.

Because value-based arrangements increase the amount of physician risk each year, there is a growing need for trust and ultimately transparency between physicians and health plans. Only with HealthPlanPhysiciansTextPhotoInsert transparency are we able develop a complete picture of patients who are at risk for adverse healthcare events in the future or who need help today. At Geneia, we believe this comprehensive 360-degree view of each patient is only possible when we integrate health plan claims data with clinical data from physicians, hospitals and labs.

But achieving complete transparency and a true 360-degree patient view is easier said than done. Health information exchanges (HIEs) have made some progress with the sharing of clinical data across the care delivery spectrum, yet siloed efforts and precarious business models have impacted their overall effectiveness. To meet the laudable goals of HIEs, every healthcare stakeholder – physicians, hospitals, health systems, health plans and consumers – would need to be steadfastly committed to the effort. In the absence of this commitment, HIEs have fallen largely short on providing useful, actionable insights and instead serve as data repositories.

Success in value-based contracts and true population health depends upon health plans and providers sharing data with each other and working collaboratively to overcome the technology, privacy and trust barriers. Shared risk across healthcare stakeholders means that health plans must trust their care delivery partners with data and related insights that enhance decision-making at the point of patient care.

Health plan data is often the only source of information about clinical events that happen outside the physician’s office and network. This kind of information helps physicians better understand future risk, care opportunities, clinical pathways and, yes, cost.

Although health plans are becoming more willing to share specific insights about at-risk populations, this typically requires care providers to use an additional tool, which the health plan provides, to effectively and cost-efficiently manage population health. As such, it’s become common practice for physician offices to work within an electronic health record (EHR) and as many as seven to 10 different systems throughout the course of a day. No wonder physicians are no longer feeling the Joy of Medicine.

Fortunately, the answer lies in a consolidated solution like Geneia’s Theon® advanced analytics and insights platform.

With such a tool, physician offices can manage all of their patients within one comprehensive platform. In most cases, this requires more raw data from health plans and a higher level of trust between the two.

Varying provider contracted rates is seen as a strategic advantage for health plans, but these variances have been shrinking over the past few years. Health plans and care providers must come to equitable agreements for sharing the quality and cost information that enables insights at the point of care, preserves business models, and drives higher value and better outcomes.
 
Likewise, care providers need to be more willing to share clinical notes, biometric data, patient assessments, and more with health plans, especially with their disease and case managers. For the past 25 years, health plans have invested millions in care management programs, all of which can now be leveraged by participating physicians. Increasingly, health plans are committed to working more collaboratively with providers and some have begun to site their care management resources within physician offices, especially in practices that serve at-risk populations. This level of collaboration is made even richer when health plan care managers can access raw data from care providers.

As someone who has worked in healthcare for nearly 20 years - a period marked by dramatic changes in healthcare delivery - I appreciate that this level of collaboration, trust and transparency is not easy. However, the open sharing of patient data between trusted partners, complemented by the right IT platform, is the best – and perhaps the only – way to achieve meaningful population health.


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