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Payers Integral in HIE Success, Experts Say

March 6, 2012
by Jennifer Prestigiacomo
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Health plans being viewed as key stakeholders in sustainability equation

With federal health information exchange (HIE) funding drying up in 2014 and with the release of the Affordable Care Act, health plans are increasingly being viewed as key stakeholders in the HIE sustainability equation.

HIEs can’t be successful unless payers get involved, said Gary Austin, principal and co-founder of TranzformHealth, a Las Vegas-based healthcare consultancy. “If you look at where the HIEs have prospered, I think the payers particularly, as well as one or two big delivery entities in the area, have gotten behind this,” he said in a National eHealth Collaborative (NeHC) webinar, “Payer Trends in HIT”, last week.

Brian Ahier, president, Gorge Health Connect Inc., a nonprofit HIE in Oregon, said during a NeHC webinar yesterday on the “Implications of a Shifting National HIE Architecture” that there is a movement underway of private payers acquiring HIE technologies to help the industry transition from a fee-for-service environment to pay for value. Last year’s acquisitions of Axolotl (San Jose) and Medicity (Salt Lake City), by United Health Group’s Ingenix Division (Eden Prairie, Minn.) and Aetna (Hartford, Conn.), respectively, are two prime examples of this trend.

“I don’t see providers on the burning platform for accountable care; I do see payers on the burning platform with the Accountable Care Act having made their previous business model no longer viable— now payers have to manage risk instead of rejecting people who are sick,” said Vince Kuraitis, principal of the Idaho-based healthcare consultancy Better Health Technologies LLC., during yesterday’s NeHC webinar. “That is a key leverage point when thinking about who’s really incentivized to make health information exchange [the verb] happen. The payers are an underleveraged stakeholder.”

Partnering in Ohio
Payers will be a key stakeholder in Ohio’s statewide HIE, ClinicSync, which is run by the nonprofit public/private Ohio Health Information Partnership. The Partnership is not only the state-designated HIE, but also the state’s regional extension center (REC), whose goal is to help 6,000 Ohio physicians and providers adopt EHRs. The Partnership has exceeded that goal already, having connected 6,200 providers.

The Partnership’s CEO Dan Paoletti made a bold statement during the “HIE Growth & Utilization: New Views on Sustainability” session at the HIMSS12 HIE Symposium that ClinicSync is projected to generate more revenue by 2014 than its nonprofit mission allows if it’s rate of adoption continues to climb. ClinicSync’s original model estimated that 125 hospitals would be needed to contribute fees to allow for self-sustainability. Currently, ClinicSync has 56 hospitals onboard, with a goal to hit 80 hospital contracts by the end of the year.

“What we did not anticipate was the incredible interest from the payers and the long-term care facilities, the physician practices themselves, home health, a whole variety of stakeholders that have come to the table to say, ‘we’re willing to contribute some dollars to this as long as we can solve some business problems we have,’” says Paoletti.

Dan Paoletti

This interest from payers and other stakeholders has led The Partnership to reevaluate its fee schedule later this year to make stakeholders’ contributions more equitable, says Paoletti.

Other than offering implementation guidance for hospital connections to ClinicSync, and working with EMR vendors to make these connections streamlined and affordable, the HIE is making sure it gets payer integration right. “They are critical to any sustainability model,” says Paoletti. “I feel pretty adamant that any sustainability model has to include that group, and we have to help them improve patient care and help them solve business problems.”

ClinicSync will seek to solve three main payer pain points: transmitting alerts through the exchange when a “covered life” presents at an ER; transmitting care summaries after patient discharge; and coordinating and streamlining documentation about what is authorized versus what care procedures actually take place during a patient stay.

A report by the Washington, D.C.-based NeHC, “Secrets of HIE Success Revealed: Lessons from the Leaders,” last year included case studies on 12 successful, sustainable HIEs nationwide. Three of the HIEs profiled in the NeHC report, Quality Health Network (Grand Junction, Colo.), Availity (Jacksonville, Fla.), and Rochester RHIO, drew much of their success from incorporating the payer community as a key stakeholder, leader, and revenue source from the beginning. These HIEs convinced payers of the benefits of the HIE's services in terms of cost savings achieved through reductions in services utilization, NeHC's CEO Kate Berry noted in a review of the report.


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