By Krithika Srivats, Senior Director, Health/Clinical Center of Excellence at Hinduja, Global Solutions (HGS)
The healthcare industry has experienced unprecedented change in recent years. Technological efficiencies and strategic service offerings, value-based care initiatives, and federal and state mandates have converged with the goal of creating a system that is patient-centered and outcomes based, while also lowering the overall cost of care.
This paradigm shift has made it inevitable for healthcare stakeholders to collaborate. More importantly, payers and providers are increasingly transparent and aligned toward better patient outcomes. As one example of legislation changing landscape, the HITECH act and mandates around quality reporting initiatives have paved the path to transparency, for better data tracking and reporting abilities across payer and provider systems. .
This article will explore the critical data management issues payers and provider share — and potential solutions to create a more seamless and transparent flow of information.
Defining The Problem
The amount of data attached to every patient has grown exponentially — and all of it has to be gathered, integrated, and interpreted according to compliance guidelines and processes that can vary widely between payers and providers as well as between jurisdictional boundaries. Additionally, the datasets held by payers and providers can be different. For example, payers possess data on claims, financial analytics, and risk models. Providers have administrative and clinical data that includes case histories and outcomes.
Each data set is valuable, but in isolation doesn’t provide a holistic and contextual perspective of the patient. Providers need to leverage health plan data in order to move from episodic care to delivering outcome-based care across the care continuum. Payers need access to patient information in order to work with providers to establish appropriate care plans for their members.
Another data management problem is redundancy. Though many health plans separate risk adjustment activities from HEDIS, Medicare Star rating system and care management activities, they all need the same patient medical record, forcing providers to dedicate significant financial and administrative resources to respond to seemingly duplicative requests with few guarantees that the information they are procuring is timely and accurate.
Last but not the least, accurate interpretation of the data is highly dependent on the completeness and accuracy of the data. Payers have had standardized methods of capturing data sets. For example, irrespective of how the claims are submitted, they cleanse and capture it into a data transaction standard that can be used across all stakeholders. However, providers’ systems are disparate with lacking stringency in data capture standards. While registries at point of service have significantly improved the availability of data, the completeness and usability is a key opportunity area. Meaningful use of the HITECH reform is still in phased implementation, and the small group and individual providers who constitute to 40 percent of providers in the USA fall under this category. The key is to forge pathways where these two data spheres overlap, turning the data into rich, actionable information that benefits both stakeholders, and more importantly, their customers. Tools like self-service portals allow both payers and providers to access complete, actionable information (as opposed to raw data), reducing administrative burdens for both parties, achieving higher-performance goals, and identifying coding and care gaps more quickly.
Improving Data Management
In terms of maintaining a healthy provider-payer relationship, the means is nearly as important as the end. Proactively, health plans and providers can improve their internal processes for collecting data in four key ways:
The increasing use of automation is fundamentally changing the healthcare business. Automation reduces or eliminates manual processes for many tasks with data-intensive processes, across multiple domains and verticals. Automation can drive tremendous accuracy while simplifying a much more robust view of our patients, members, and customers’ unique healthcare needs.'
In the past, both payers and providers have attempted to bridge data gaps through costly manual processes, which has resulted in enormous costs. According to the 2016 CAQH Index report on healthcare’s adoption of electronic transactions, the administrative costs of closing those data gaps consumes nearly $300 billion per year—about 15 percent of all healthcare expenditures.
More than the enormous cost, these inefficiencies have led to greater payer-provider abrasion and increased patient/member dissatisfaction.
Processes such as strategic automation and business processes outsourcing can make a significant difference in payer-provider engagement and transparency, as well as the cost of doing business. At the front desk and in the back office, payers can help provide tools that enable providers to submit claims electronically rather than manually and to check what is authorized at (or even before) the point of care.
- Manage Data Requirements
By understanding how data is captured and used throughout the organization, health plans may be able to streamline processes simply by sharing data that already exists. For example, the claims and network management departments both rely on service and payment addresses. If one becomes aware of a new address, there should be mechanism that alerts the other of that change. Similarly, encouraging and incentivizing providers to use the web portals for communications and requests as well as in sharing information will not only ensure timeliness of data exchange but also reduce errors in translation, from one source to the other.
- Identify Key Staff Members At Provider Facilities
Different staff members within a provider facility handle different types of information. For example, the person who answers information about claims may not be the same person who handles risk management inquiries. But more often than not, the person answering the main line at the provider office doesn’t know how to route these calls. Health plans can reduce some of this churn by having the name and contact information for key staff members who can handle their request.
- Rethink Data Collection
Is it more important to get all the data, or is it more important to get clean data? The answer is both. In the short term it can be tempting to capture the minimum number of data elements required to meet the federal and state mandates. However, health plans and providers should also consider long-term requirements and opportunities for future improvements when building their data schema.
The transition from fee-for-service to fee-for-value payment models creates a need for better communication and coordination between health plans and their provider networks, which means that both stakeholders will need to address the challenge of how data is collected, communicated, stored and updated. Realizing these goals will require health plans and their provider networks to rethink their business workflows. However, through the aggregation of member and clinical data, insurers and their provider networks gain the ability to continuously evaluate the customer lifecycle and foster a more transparent process for data-sharing.