Imagine the following scenario. You discover that you are the victim of identity theft, purchases have been made in your name, and your personal credit has been ruined. You are saved, though. You have paid a watchdog organization to monitor your credit, and they have information that clears your good name! So, when you apply for a loan with a bank, you request the credit monitoring agency to share the details of your prior credit problems and its resolution with the bank. But the monitoring agency will not share that information because that might help the bank understand your needs and negotiate a better price for their own credit monitoring service that they resell to their customers – i.e., you. The monitoring service won’t release your information.
Would you put up with this conflict of interest? NO!
In healthcare, we routinely tolerate a form of this conflict of interest, and in many different forms. Even though health insurers are not providing the patient care directly, these payers tend to accumulate a very useful holistic view of each patient’s history, including information from the perspective of what care was provided based on payment being demanded by many different care providers. There are numerous instances where, if this information was shared with other providers, it could positively impact the care management plan, doing so in a more timely manner, and increasing the likelihood of improving the quality of care the patient receives and possibly reducing the overall cost of care across an extended episode.
Here is an example- A patient is admitted to the hospital and receives a pacemaker to address his atrial fibrilation. After being discharged, the patient follows up with his cardiologist who has reduced the dose of digoxin, having diagnosed the patient with a digoxin toxicity. However, the patient attempts to save a few dollars by finishing their current prescription only to be admitted to the hospital a couple of weeks later for the toxicity. This is an opportunity where the care manager could have intervened based on the cardiologist’s toxicity diagnosis being submitted to the payer and no prescription was filled within a few days. The care manager could have helped the patient be more compliant with the cardiologist’s instructions avoiding an inpatient admission.
Healthcare provider organizations and payers (and in some cases regulators) are working together to break down these walls in an effort to increase value across the spectrum of care delivery and the industry in general. However, the sometimes conflicting vested interests of these interacting payers and providers can still be an obstacle, influencing the politics of information disclosure and sharing in the emerging environment of accountable care delivery models.
There is great diversity in the participating organizations that collaborate to make up an ACO. This is definitely not one size fits all. Viewed from the perspective of sharing risks across parties without the immediate concern about maximizing volumes, the integrated provider-based health plans, such as Kaiser Permanente, Geisinger Health System, and Presbyterian Healthcare Services, are already inherently sharing this risk and are reaping the rewards as a single organization. That’s great for the few organizations and patients that are already members participating in one of these plans.
Unfortunately, for other organizations there is still much more to be worked out regarding proactive sharing of data both within an accountable network of providers acting across care settings, and with the payer(s). Within the network, hospital systems usually have some of the infrastructure in place and they know how to routinely share data between systems and applications using standard data exchange conventions such as HL7 and CCD. In collaboration with HIE’s these systems can help facilitate active data distribution, and they very often provoke the organization to address some of the more common aspects of data governance. However, even when this routine “transactional” and operational data is being exchanged and coordinated, there is still a great unmet need for the ACO to buy or build a data repository for the integration and consumption of this data to support reporting and analytics across various functional areas.
Many organizations encounter further challenges in defining and agreeing on which are the authoritative sources of specific elements of data, what are the rights and limits on the use of these data, and how can these assets be used most effectively to facilitate the diverse objectives of this still-emerging new organizational model.
An even greater challenge for some ACOs is collecting the required data from the smaller participating provider networks. These organizations often have less capability to customize their EHRs (if they even have EHRs in place) and less resource capacity to enable the data sharing that is required. To get around this, some ACOs are:
- Standardizing on a small number of EHRs- (ideally one, but not always possible) This provides the potential to increase economies of scale and leverage the shared learnings across the extended organization.
- Manually collecting data in registries– Although not always timely, this addresses some rudimentary needs for population-focused care delivery and serves to overcome common barriers such as the willingness of a given provider to collect additional required data and complying with standards.
- Not collecting desired data at all– While this seems hazardous, progress toward the overall clinical and/or financial goals of the ACO can still be positive, even if an organization cannot directly attribute credit for beneficial outcomes or improvements within the organization, and the ACO can avoid the overhead of collecting and manually managing that data.
Regardless of what data is collected and shared within the ACO, the payers participating often have the highest quality, most broadly useful longitudinal data because:
- The data is ‘omniscient’ – it represents, in most cases, all of the services received by (or at least paid for) that patient – provided a claim for those services has been submitted and paid by the participating payer.
- Some of this data is standardized and consolidated making it easier to manage.
- The data is often enriched with additional data residing in mature information systems such as risk models, and various disease-focused or geographic populations and segments.
Consequently, payer data very often forms the longitudinal backbone that most consistently extends across the various episodes constituting a patient’s medical history and is very important to the success of the ACO’s mission to drive up quality and drive down costs. Despite this opportunity for an ACO to improve its delivery of care to targeted populations, sharing of data is still achieved unevenly across these organizations because some payers feel the utilization, cost and performance data they have could be used to negatively impact their position and weaken their negotiations with the hospitals and other provider organizations.
While claims have traditionally been the de facto standard and basis for many of the risk and performance measures of the ACO, more progressive payers are also now sharing timely data pertaining to services received outside the provider network, referrals between and among providers, authorizations for services, and discharges, further enabling ACOs to utilize this information proactively to implement and measure various improvements in care management across the spectrum of care settings visited by patients under their care.
Collaboration between provider organizations and payers at a data level is moving in a positive direction because of the effort given to ACO development. These efforts should continue to be encouraged so as to realize the possibilities of leveraging timely distribution of data for better treatment of patients and healthcare cost management.