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Linking Providers and Payers

September 1, 2011
by Jennifer Prestigiacomo
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HIE most effective way to bridge the gap and affect quality at point of care

Sharing clinical information among providers and payers via health information exchanges (HIEs) can improve quality at the point of care and help drive down costs. This salient message, as well as others, were delivered at an eHealth Initiative (eHI) webinar “Bridging the Gap between Providers and Payors” on Monday, which brought the two groups together to talk about how best to collaborate on patient care and healthcare utilization.

John Haughton, M.D., chief medical information officer, Covisint (Detroit, Mich.), suggests that payers and providers can have deeper partnerships, and more specifically that payers can make their resources, like call centers or direct mailing capabilities, available to providers for care coordination. He cited successful provider/payer partnerships like Blueprint for Health, Vermont’s medical home project, and Presbyterian Healthcare Services, an eight-hospital system in New Mexico, as models for success.

Jamie Ferguson, vice president, health IT strategy and policy, Kaiser Permanente (an Oakland, Calif.-based integrated health system), drove home the fact that HIE is the way his organization enables decision support at the point of care. He noted that it’s not the type of HIE technology that matters—be it the VA’s Blue Button, the Office of the National Coordinator for Health IT’s Direct Project, a proprietary system, or the Nationwide Health Information Network (NwHIN)—it’s the “integration of computable data” that matters most.

Ferguson said his organization realized that clinical information when using it in real-time for patient care was incredibly important to patient safety and shared a telling story of its use. “One of our first patients was a veteran who had neglected to mention the occurrence of two new life-threatening medication allergies, one a statin and one a hypertensive, that had been documented at the VA [U.S. Department of Veterans Affairs]. So they knew about it but we didn’t,” he said. “When his Kaiser physician pulled his C32 record from the VA he was able to see those and that the patient’s last cholesterol and blood pressure were not controlled, so it would have been very easy in that case for the clinician to prescribe a drug in the same class as the allergy; so a potentially life-threatening event was avoided.”

Kaiser Permanente has invested in care partnerships like the Virtual Lifetime Electronic Record (VLER) to share HL7 continuity care documents in real-time during patient visits. Ferguson also mentioned that his organization recently cofounded the Care Connectivity Consortium, an interoperability group with members Geisinger Health System (Penn.), Mayo Clinic (Minn.), Intermountain Healthcare (Utah), and Group Health Cooperative (Wash.), to utilize standards-based health IT to share data about patients electronically. Ferguson said that payers with interest in care quality and cost reduction can embrace the same methods as these provider organizations.

Health Information Exchange Considerations
Ferguson did caution that even with the many benefits of HIE, there were considerations to explore as several markets mature. One market he had his eye on was rapidly advancing genomic sequencing technology and its implications on patient privacy. “If you accept that your genomic signature is going to be increasingly common, that it’s something that gets done in a doctor’s office, instead of something in a very important research study as it’s done today, then who are you going to trust with your genome?” Ferguson asked. “Health information exchange also depends on sustained public trust.”

Other barriers to HIE Ferguson noted was that the industry still lacked a unique patient identifier and named in “the biggest unsolved issue today.” He also advocated the need to streamline and automate operational process and requirements for patient authorization and consent that vary by jurisdiction and law processes in order to expedite HIE.

HIE Sustainability
Payers and providers play a direct role in HIE sustainability and need to reach immediate goals of mutual value of lower operating costs like reducing redundant tests, said Sam Ho, M.D., executive vice president and chief medical officer, United Healthcare (Minnetonka, Minn.). “What we see beginning to emerge, particularly in some of our medical home pilots, is use and exchange of clinical information to get a better view in terms of medical management and getting more complete data at the point of care to assess the cost effectiveness of services, [help providers make] determinations closer to real-time that actually obviate the need for unnecessary diagnostics studies and treatment referrals,” said Ho.

Ho shared some early examples of what United Healthcare was doing to work with providers, which included reconfiguring its physician portal to look at physician-specific Healthcare Effectiveness Data and Information Set (HEDIS) evidence-based gaps in care, by patient, condition, and clinical service. “This has the tremendous opportunity for not just quality improvement, but improving performance measurement at the individual physician level,” he said.

United Healthcare has also been sharing emergency department (ED) and inpatient utilization with primary care physicians, which is where Ho said most discretionary spending occurs and where the most impact can be achieved in terms of developing more affordable services. This could create opportunities for patient coaching to reduce ED overuse and misuse, he said.

United Healthcare’s strategy is based on quality and cost outcomes directly related to HIE activities that are continuing to mature, Ho said, and his organization will eventually change contractual architecture to give value payments over time to reward higher quality and lower cost. “In terms of what payers are doing for sustainability, [the key ] is to have shared incentives,” Ho said. “Once the incentives are aligned, the payment is aligned around improving quality and managing cost for an entire population, I think we’ll be better served.”

Beyond short-term goals and the progress the industry is making on multi-payer databases, Ho sees the future of quality and cost measure analysis in standardization. “In a future-state using HIEs to look at appropriate benchmarking and quality and cost parameters by specialty, by clinical condition, by site of service, by co-morbidity is going to be very exciting,” said Ho.


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