Towards the next generation of health plan and provider data sharing

Imagine a world where data exchange between health plans and providers is fully integrated. A world where health plans and providers engage in real-time data sharing at the point of service; where providers are able to access the entirety of a patient’s clinical and administrative data to support decision-making; where new patient data is automatically uploaded and accessible to clinicians and plan administrators.

It’s a world where data flows as close to the source as possible, bi-directionally, in real time; where operational business processes and tools are aligned across the various health plans or providers; where data is centralized and is accessible at the points closest to the decision-maker. This is a world where clinicians enjoy unprecedented access to practical and actionable insights; where clinical observations support recommended actions and where health plans and providers collaborate to produce optimal patient outcomes. Allowing patient outcomes to improve as they receive well-informed and more efficient care.

The benefits of a world characterized by enhanced data exchange between health plans and providers would allow for a fundamental shift in the quality of medical care. Health plans and providers would experience less complexity in interactions with their counterparts, which would lead to fewer disputes regarding the validity and interpretation of data. Health plans and providers would also realize significant efficiency benefits which, in turn, would help better manage their operational costs and better serve their clients.

Achieving such a world is possible, however there are several hurdles to overcome to achieve such an outcome outside of the data interoperability challenge. Legal/privacy issues, central storage, limited provider participation and the question of who manages the data and the costs, just to name a few; however, this is the future considering the ongoing evolution and progression towards value-based care models.

Four fundamental elements of next generation data sharing

• Great access to data. Whether it’s stored in a super data warehouse or linked together through Application Programming Interface (API) and data wrangling tools, all parties in the patient value chain will require unprecedented access to a central clinical repository – an architecture that allows your organization to gather data from many sources and act on it all at one time. Data sharing must be in real-time and bi-directional with both health plans and providers able to read and write the data.
• A longitudinal view of the patient. Both health plans and providers need to be able to seamlessly track patients over time and place. Understanding how patients move from one plan to another or from one provider to another and being able to see their complete clinical and administrative data will require more sophisticated identity management solutions and collaboration.
• Actionable insights. Raw data alone does not lead to improved financial or patient outcomes. It must first be converted into information that can be delivered to the clinical or administrative team at the point of service. Tasking clinical teams to work with data scientists to uncover information from the rich sources of data will be key to unlocking the value of data sharing.
• Improved tools and capabilities. At the very least, new data sharing models will require both health plans and providers to adopt new technologies and enhanced capabilities at the implementation phase. Over the longer term, these investments will be invaluable in helping to support the shift to value-based care models.

Widening the narrow view

Unfortunately, few, if any, health plans and providers are making significant progress towards achieving this level of data integration.

Indeed, for the most part, the exchange of data between health plans and providers continues to be limited and focused primarily on administrative and billing information. Additionally, the data that is being shared is limited to health plan and provider data particular to their transaction.

Even if health plans and providers were sharing all of their patient data (both clinical and administrative) across the entirety of the patient record, the timing of information would still be an issue. Few, if any, organizations are currently capable of sharing patient data among organizations in real time. In most clinical settings, anything less than real time makes it too slow to be truly actionable.

Paralyzed by complexity

What’s holding health plans and providers back? For a variety of legitimate reasons, persistent resistance to true transparency and lack of trust in data accuracy and intent is still a driving force in limiting true data sharing and collaboration. The complexity of the health plan and provider markets doesn’t help the situation. Health plans interact with hundreds of different provider specialties. Some providers may be large urban Accountable Care Organizations (ACOs); others may be small rural independent practices. The provider ecosystem isn’t much simpler. Many providers deal with at least a dozen different health plans that offer multiple different products.

The reality of this fragmented marketplace is that both health plans and providers need to manage multiple different data portals, formats, tools and processes in order to manage their current relationships. Increasing the volume and type of data being shared across this fragmented market seems like an overwhelming task, not to mention developing the business models and governance frameworks that would be required to manage those relationships.

Looking for the carrot  

Our view of the market suggests that many health plans and providers are also being held back by a lack of incentive. Given the range of other massive changes now disrupting the health plan and provider markets, few decision-makers see investment into improved data-sharing as a priority. Since the vast majority of healthcare services and payments are still being delivered under fee-for-service models, many decision-makers feel enhanced data-sharing is not a priority.

Talent and capabilities are also a problem, and not only at the technical level. Integrating and maintaining a highly sophisticated data-sharing platform at the plan and provider level will require organizations to radically rethink their skill and capability set; this will also require new strategic capabilities at the decision-making and planning level. Our experience suggests that few health plans or providers have the full range of skills required to make the transition alone.

Technologies are emerging to solve the problem

Currently there is a growing ecosystem of new and updated technologies that are being applied to help health plans and providers address challenges associated with next generation data management. 

Over the past few years, we have seen a new set of software vendors emerge, focused on helping providers manage population health data and measurement. Unlike current electronic medical record (EMR) systems that prioritize getting the bill developed and delivered, these platforms and tools are designed to help health plans and providers see all of the patient data in a single location. Some versions include clinical data repositories, member identity management solutions, linear data models, and integration hubs that can gather data from health plans and distribute data out to EMRs.

Alongside these new technologies is another class of vendors focused on the analytics side of the equation. These cloud-based analytics providers offer very specific healthcare use cases that, when supported by the right data, are able to uncover important insights about where to apply member-specific interventions. Cloud-based analytics providers can be found in virtually every specialty area and for every type of practice.

Yet, while these new technologies and adapted suites certainly offer a glimpse of the future, our experience suggests they do not, in and of themselves, represent a silver bullet. Indeed, Baker Tilly has worked with a number of plans and providers who, having purchased and installed a range of technology suites, now find themselves no further along than they were before. What they came to realize is that new technologies also require new processes, new models and new capabilities in order to deliver value.

Looking through both lenses     

When we work with leading health plans and providers, we often focus on helping decision-makers build their data sharing and technology roadmaps with a view through two different lenses. The first is the short-term lens of the immediate pressures, e.g., reducing friction, cutting costs or executing on contractual agreements. But the second lens is the long-term view of the anticipated future: the world where value-based care models are prevalent and data-sharing between plans and providers is fluid.

The key is to continuously look through both lenses: finding opportunities to address the short-term priorities in ways that allows the organization to build towards a future model. Given the disruption now in the markets, this is not an easy task. However, Baker Tilly believes that there is a framework that health plans and providers can employ to help guide their long-term and short-term decision making when it comes to data-sharing.

Our view suggests that health plans and providers should carefully consider what the future of data-sharing will look like, how it will create value and what skills and capabilities will be required to achieve that vision. Most providers’ five-year capital plans are still replete with enhancements that focus on improved market share and new care venues while not acknowledging the data-sharing demands of value-based care. They should also be taking the time to conduct an independent review of their current risk readiness and performance management tools to assess and quantify the long-term objectives for their organization.

The next generation of data-sharing between health plans and providers is clearly progressing, and the benefits will be tremendous, if conducted appropriately. Now is the time to start preparing for the journey.

For more information on this topic, or to learn how Baker Tilly healthcare specialists can help, contact our team.