Payment Trends

Insurer Data Requests Prompt Hospital Policy Overhauls

March 12, 2018 8:48 am

One health system said it has started to provide the data to payers to encourage reciprocal data sharing.

March 12—As health insurers increasingly get involved in patient care management, they are requesting clinical data on individual patients from hospitals and health systems.

The new requests are prompting providers to redesign the way they review and process payer requests for patient information to protect patient privacy and enhance patient care while not requiring significant resources. It’s an example of the rewards and pitfalls of interoperability between payers and providers, which previously have had strong firewalls on patient data.

“We are receiving more requests from payers to access and receive clinical data,” Steven Lane, clinical informatics director of privacy, information security and interoperability at Sutter Health, a large Northern California health system, said this month at HIMSS 2018, the largest health information technology conference. “We respond to these requests in a way that is cost effective and also respects patients.”

Sutter Health’s strategy on the new requests required developing new protocols on patient data sharing and forming new committees that review each insurer request on an individual basis, Lane said.

“When we entertain each request we need to think about each use case and make sure it is appropriate to share the data,” he said.

While electronic health record (EHR) system adoption has made it much easier to share patient data with payers, EHRs can create more work around data sharing because providers must make sure that the data shared complies not only with the request but is in line with patient privacy laws and doesn’t break patient trust.

Some payers wanted direct access to Sutter Health’s EHR to get patient data, Lane said. “We declined because it is hard to lock down information beyond what they were asking for,“ he said. Sutter Health is exploring possible ways to improve data sharing, such as regional health information exchanges and developing interoperability standards for the exchange of healthcare information electronically.

For now, Sutter Health extracts the requested data from a patient’s EHR on an individual basis after requests from providers and are approved by an internal review committee, Lane said.

“The requests [from insurers] keep changing and we have to reassess each time,” Lane said. “We have to ask: What is the value for us? It’s not free and the value proposition has to align with our strategy.”

Review Process

Sutter Health developed specific criteria on the requests. For instance, whether the request aligns with the health system’s quality improvement activities and whether the payer’s patient interventions dovetail with the provider’s care plan. Like many health systems, Sutter Health is seeking to enhance care coordination and care transitions across inpatient, outpatient, and the home environment. The committee reviews each element of each specific payer request, which can include requests for patient encounter notes and specific time periods of treatment. Finally, the committee reviews legal parameters around sharing data on specific patient diagnoses including HIV status, substance abuse, and mental health conditions that have stronger patient privacy protections.

“We look at this in a meticulous way,” said Lane.

The landscape around provider-payer data sharing is changing rapidly. In January, the U.S. Department of Health and Human Services Office of the National Coordinator for Health IT released its draft Trusted Exchange Framework and Common Agreement, required by Congress as part of the 21st Century Cures Act of 2016. The framework lays out parameters on data exchange and patient access.

In the private sector, the Da Vinci Project, established in January 2018, is a collaboration of payers, providers, the federal government, and health IT technical experts to accelerate adoption of FHIR (pronounced “fire“), an interoperability standard for electronic data exchange of healthcare information.

Lane, who serves on an advisory committee for the Cures Act, said that both the framework and the Da Vinci Project are avenues to facilitate and promote appropriate data sharing among stakeholders.

“I can’t stress strongly enough that we want to get data out of payers,” Lane said. “In return for us giving them data, we expect to more easily get data from them.”

For instance, payer data can help providers conduct more accurate population health risk stratification. Claims data, including preventative screenings conducted at other health systems, can provide a more complete picture of a patient’s health and reduce redundant and unnecessary testing, he added.

Payer’s Approach

Reducing duplication of efforts is a shared goal of Blue Cross and Blue Shield of Minnesota, which has embarked on its own patient data sharing strategy with regional providers.

The not-for-profit health plan, which serves about 33 percent of all people in Minnesota, developed a Center of Excellence two years ago to begin addressing care gaps for its members.

Victoria Losinsky, PhD, pharmacy service director for star rating and enterprise risk adjustment at the Center for Excellence for BCBS of Minnesota, said the health plan took the unusual step of purchasing an EHR system to improve interoperability. Losinsky spoke on a panel with Lane at the HIMSS Interoperability Showcase.

Previously, BCBC of Minnesota relied on claims data, which was many months to a year old, to determine which patients might be candidates for chronic disease outreach programs provided by the health plan. A chart request to a provider might reveal additional information about a patient, but it was also an unreliable data source, Losinsky said.

“Using our EHR platform, we get claims data and leverage information flowing in from the provider,” she said. The health plan then contacts eligible patients for appropriate case management on chronic conditions such as uncontrolled diabetes or COPD. Patients with multiple chronic conditions may qualify for intensive medication management through the health plan as well. Patients allow BCBS of Minnesota to access this information through agreements on the condition that the data is only used for care coordination purposes.

“There is no way that this information could be used to approve or deny payment,“ Losinsky said. “It’s completely firewalled off.”

In the future, Losinsky said she sees more bi-directional information sharing.

“This is very much a one-way street right now and we know one way streets don’t help patients,” she said. For instance, the information gathered by health plans could flow back to providers to enhance star ratings and HEDIS measurements for care improvement, she said.

“We need to be thoughtful about making it actionable,“ she said of the data.

Rebecca Vesely is a freelance writer based in San Francisco. Follow Rebecca on Twitter @rebvesely


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