PwC Report: With Population Health, Payers and Providers Have to Play Nice | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

PwC Report: With Population Health, Payers and Providers Have to Play Nice

September 28, 2012
by Gabriel Perna
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As the healthcare industry embraces an outcomes-based approach from a population health standpoint, a recent report from PricewaterhouseCoopers (PwC) Health has looked at the power of the payer-provider collaboration in terms of sharing and integrating clinical data. The authors of the report conclude that it is payers who hold the treasure trove of useful data, and when combined with providers’ clinical systems and expertise, that data can produce better results for patients.

“When working with payers, providers, and pharmaceutical companies, we’ve noted that the one with the most information that could typically help support population health and allow the sharing of information to begin to occur, is not the provider – it’s the payer,” says John Edwards, director of healthcare strategy and healthcare business intelligence practice at PwC, and one of the report’s authors, in an interview with Healthcare Informatics. “Most payers have made significant investments in data on their consumers, about their healthcare.”

While much of the data coming from the payer side is administrative and lacks a clinical richness, the bills come with procedure codes and provide a longitudinal record that has been in place for multiple years. Edwards says the authors of the report had begun to see examples where payers were sharing that information and using to empower the physicians. This information allowed payers and providers to form partnerships, which tied into incentives, bonuses, and how the payment structure would occur.

“More importantly, it started to forge the possibility of thinking about quality of care for the population and learning from studying the practice of care across the population,” Edwards says. “When you think about it, a given doctor may see two to four thousand patients in a year, while a payer has one million, five million, maybe 10 million patients in its system. They have more complete information on clinical care than any one doctor. So what might be rare care for a doctor in their portfolio, the payer probably has multiple examples of people with that condition, and they’re able to see how different doctors ordered different procedures. From that, they can create a new dialogue with those providers.”

For years, the report says, insurers have been using data to squeeze excess cost out of the system. With changing reimbursement models, including the rise of accountable care organizations (ACOs), the payers’ role is expanding. Not only does data integration lead to a cost-savings for all parties, Edwards says; payers can provide information that becomes actionable for the providers. The winners of this collaboration, he says, will be the patients.

Examples of Payer-Provider Teamwork

The report’s authors looked at several pilot programs already integrating this kind of data, which Edwards says he and his colleagues had seen popping up across the country. He mentions Hartford, C.T.-based insurer, Aetna, which is using clinical and payer data, forming partnerships with hospitals and providers, and making it available for employers and consumers. He says this effort not only empowers the provider, but it increases consumer engagement.

Another initiative also looking to increase consumer engagement through data and other technology integration comes from Oakland-based, integrated provider and payer, Kaiser Permanente. Edwards says Kaiser is using filmed interactions between providers and payers, along with data analytics from the payer side, to improve communications at the point of care. Kaiser developed this initiative because it recognized that a lack of communication was a huge reason for high readmission rates. Using the data analytics and video component, Kaiser’s 30-day readmission rates at one medical center fell from 13.6 percent to 9 percent in six months.

Edwards says integrated systems such as Kaiser’s and that of Danville-Pa.-based Geisinger, which was also mentioned in the report, having created a data analytics tool used that is used to track medication compliance in certain conditions, typically have an advantage that others attempting to form these partnerships do not. For one, an integrated payer-provider system will have easier access to the right set of data expertise, on both sides. Also, the familiar barrier that providers and payers face when attempting to trust the other side is usually removed in an integrated system. However, that’s not always the case, he says.

“I have seen some companies where the hospital system owns a payer, and those traditional barriers of trust, are as solid as they ever were. The purchase [of a payer by a hospital system] doesn’t automatically remove those barriers of trust,” Edwards says.

Along with the Aetna example, the report includes other pilot triumphs from non-integrated entities collaborating together. In fact one such example, Edwards says, is the perfect example of a successful payer-provider partnership. The initiative between the Indianapolis-based payer Wellpoint, the Armonk, N.Y.-based tech giant IBM and its Watson technology, and a large academic medical center, the West Hollywood-based Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute, is “the most far reaching example we’ve seen,” according to Edwards.

The initiative uses Watson, which became famous for winning on the game show Jeopardy!, and its ability to process an abundance of clinical information to help better guide the clinician when they are treating the patient. “The level of investment [for this initiative] is not something all payers and providers can make, that really is leading edge. But it’s a great example of where the future practices of medicine can go through aligned partnerships.”

Evolution of Incentives

Edwards is confident about the future potential of the payer-provider collaboration and how this can expand beyond those who are leading edge. Thanks to incentives from the Centers for Medicare and Medicaid Services (CMS), Edwards says, there are now more reasons than ever for payers and providers to collaborate. He cites the measures for the CMS star ratings for Medicare Advantage plans, and how medication adherence is highly weighted. When this went down, Edwards says, it made the payers realize they had to partner with health systems to hit those measures.

“It caused new conversations to occur by taking the traditional incentives of the right drugs are being prescribed to the [new incentives] the right drugs are being taken. As that continues to evolve, it could be the right diseases under control because we’re seeing right value,” says Edwards, who doesn’t see the train stopping any time soon. “This evolution is occurring rapidly and it’s taking us beyond more traditional incentive programs into more shared risk around the reward programs and towards more value-based measures.”

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