Sitting at the helm of one of the nation’s most recognized health information exchanges (HIEs), in the state that’s leading the way for HIEs across the country, I often find myself explaining how Hixny and HIEs like it can support the requirements of one care management program or another.
The thing is, all of the separate constructs represented by the myriad of acronyms that accompany these programs are really intended to achieve the same goals: increase healthcare quality, increase healthcare consumer satisfaction and decrease healthcare costs. The difference is—at the most basic level—which kind of insurance is in the mix along with the provider and their patient.
For example, New York’s Delivery System Reform Incentive Payment (DSRIP) program and the state’s efforts to help primary care providers transition to patient-centered medical home (PCMH) models are both tied to efforts involving Medicaid. Accountable care organizations (ACOs) are tied to Medicare. And the blanket term “value-based care” (VBC) is a longstanding initiative among commercial health insurance companies that have their own PCMH and enhanced primary care structures—while encompassing the state-based Medicaid and Medicare efforts, as well.
Every insurance company or public insurance program is trying to do the same thing: lower costs and improve quality. To do it, they all need the same things from the HIE—and so do their providers and patients. That is, they all need access to information. And the HIE is the only service that can deliver community, regional or other aggregated benchmarks to help care managers compare populations and performance against VBC goals.
All of the data they seek is provided in other places. Clinical data is in electronic health records at providers’ facilities. Claims data lives in the insurers’ databases. And the critical social factors that play a determining role in people’s health, especially among Medicaid and Medicare recipients, are often collected by community-based organizations.
Even within the HIE, different registries—lists of people who meet criteria for specific conditions or behaviors that require medical intervention to prevent complications or reduce costs—are more or less useful to providers and insurers participating with different programs.
Yet, VBC and related programs aren’t new. As far as back as early 1990s, health management organizations (HMOs) were pushing risk from insurance companies to providers. At the time, global arrangements didn’t work as envisioned. Now, while the data is available from all of the sources above, there’s no single place where it’s consistently aggregated and tied together. There’s no complete view available of a patient’s condition and health risks, along with the social factors that may influence their behavior around seeking treatment and following the prescribed treatment.
In fact, real-time clinical information pulled through the HIE may be compared against six-month-old claims data pulled from an insurance database.
It’s only when all information is available in a single setting—and as quickly as possible—that aggregation, comparison tools and information highlights work together to create a complete picture of the patient for both providers and insurers. That includes quality metrics and registry data, as well as the explanatory data that gives context to cost and quality. Drawing all of the pieces together offers a truer view of the complexity of circumstances facing a patient so that a provider and an insurer can more effectively manage their care.
Different organizations are approaching these challenges in different ways. At Hixny, as at many HIEs, we believe that we have the greatest capacity and capability to serve as a hub and facilitator for all of the types of data that participants in these programs need.
That’s why we’re working to build not only the clinical data flow, but also the flow of pre- and post-adjudicated claims data. We’re working with commercial insurers, too, to contribute claims data through Hixny and use Hixny as the real-time source of clinical-claims comparisons, rather than pulling clinical data from Hixny and comparing it to their own claims data offline.
Making those sorts of changes helps everyone across the healthcare community. It allows providers to view consistent data across health plans, which can inform their overall decision making at the point of care, at the same time they are being asked to assume more risk and greater responsibility for patient management to insurance company standards. That in turn, affects future costs at the same time it contributes to improving quality.