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Clinical Collaboration: Bringing Payer and Provider Together

December 24, 2014
by John DeGaspari
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How Mercy Health is breaking down silos and making data relevant to all the stakeholders

What’s the biggest challenge in bringing payers and providers together to improve care for the patient? In the view of Dan Hounchell, COO of HealthSpan, a Cincinnati, Ohio-based health benefits management company, it’s a re-thinking of how data should be used once it’s brought together in terms of how it is leveraged and who it going to benefit. The end result should be care that is squarely focused on the patient.

That’s the topic of a webinar, “What Clinical Collaboration Means Down the Line for Payers and for Data Mining,” which was presented on Dec. 18 by the Institute for Health Technology Transformation (sponsored by Carestream).

Hounchell spoke of HealthSpan’s partnership with Mercy Health, a large hospital system that he says is transforming its mission from one that is confined within “four walls,” to becoming a care management company, with a clinically integrated network, an insurance holding company, a focus on primary care and preventative care, and on managing populations.

That approach is requiring a financial and strategic “mindshift” from volume to value, and from a perception of its role of treating patients in the traditional sense to viewing patients as “members.”

Mercy Health is a complex organization, both organizationally and in its geographic reach, and makes use of many different layers and types of data from many sources.

It got into the insurance business in 2013 when it acquired the Kaiser Foundation Health Plan of Ohio. It includes a large employed physician group, and sponsors HealthSpan Partners, an insurance holding company with multiple insurance companies under it.

As a provider organization, Mercy Health covers several markets in Ohio, each with different communities and populations. HealthSpan offers HMO products in those markets, as well as statewide access to PPO products. “We have to customize how we are leveraging the data, and how we want to use it within a clinically integrated network,” he said. “It’s not cookie-cutter.”

MAKING A PRODUCT RELEVANT TO THE CONSUMER

HealthSpan’s insurance offerings are highly rated: its National Committee for Quality Assurance (NCQA) Medicare insurance plan and NCQA private health insurance plan rankings for 2013-2014 were ranked number one in their categories in Ohio.

Yet, according to Hounchell, those accolades mean little to typical consumers—patients—who often don’t “get” healthcare. Acronyms like NCQA, PCMH, ACO, and even ACA, are just that—ingredients for an alphabet soup that mean little to patients’ everyday realities. “We are not doing a great job translating it to consumers,” he said. Even the ubiquitous term “Big Data” is a foreign concept to many who are not steeped in the healthcare world, he added.

Many concepts and acronyms in healthcare are indeed translatable, though—and it’s important to realize that from a data perspective when trying to make data relevant to the consumer to maximize engagement, he noted. While healthcare-related acronyms may leave many consumers cold, they do understand product, in terms of “stars,” “likes,” points, rewards, tangible benefits, and good bargains.

While healthcare is not quite at the point where consumers can comparison shop value on an apples-to-apples basis, they do understand healthcare in terms of a good experience and a better quality of life. Getting hypertension under control may not resonate with some consumers, but if they have an active lifestyle that they couldn’t have before, that is something that many can relate to, he said.

Unfortunately, today consumer engagement is tough to cultivate in the healthcare industry, where accessing, delivering and paying for services exists in silos, he said.

ESTABLISHING AN INFRASTRUCTURE FOR COLLABORATION

HealthSpan has worked with Mercy Health to establish an infrastructure to break down those silos and allow collaboration between provider and payer sides. Those “behind the scenes” mechanisms for sharing of quality, utilization and operational data are aimed at creating a more seamless consumer experience.

For that to happen, there needs to be data transparency—ready access to actionable data—without which, “you will never know if you are accomplishing the goals you set out to accomplish,” Hounchell said.

The infrastructure for integration of quality and cost reduction, which consists of the building blocks of an electronic medical record (from Epic); patient-centered medical home (PCMH); care coordination; and network development to align the offerings of physician practices and specialties.

Even with such an infrastructure in place, Hounchell acknowledges that the needs of payers and care teams are different. In care coordination, the clinical focus is on managing the sickest patients, while the health plan is interested in identifying the most expensive patients and why. While there should be a high level of integration on the back end, “at the same time we have got to be able to pull certain data from the health plan perspective that is very different form what Mercy Health is going to be looking at,” he said.

To make use of that data, HealthSpan has created a health plan analytics infrastructure that takes in claims data, applies business rules on how the data is going to be fed and mapped to the enterprise data warehouse, and uses business intelligence and reporting tools to the various stakeholders. The analytics is supplied in two ways: operational analytics, to department heads as well as government agencies for auditing purposes; and value analytics to various stakeholders.

Each of the stakeholders for value analytics has its own interest: administration, to track how a plan is performing; consumers, who visit the health plan site; providers, interested in how they are performing relative to their peers; employers, interested in controlling their costs; and brokers, who play an important role in who buys the healthcare products and who educate the consumers.

The main challenge of value analytics in an organization where the health system and health plan are under one roof is to create value by pairing clinical data and cost data together, Hounchell said. He noted that it’s important to present the correct level of data to each stakeholder. Administration, department leaders, physicians and consumers each have their unique data needs in the level of data and the way it is presented.

Hounchell said the goal of the infrastructure is to create data products that will impact the patient experience in a positive way, and be relevant to the patient in terms of if he or she can access the service or care; if it is affordable; and if it a good experience.

To reach that point, the payer-provider teams need to agree on what the patient or consumer experience they seek to establish, Hounchell said. Every initiative within the collaboration starts with a goal to optimize the value and experience for the patient. From there, the tools are now in place to define how success will be measured, determining who owns what work, how and what data needs to be mined.


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