Health Plans Seek EHR Data For New Payment Models

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Health plans are rapidly migrating to value-based payments models, according to a new report from Availity, which provides Web-based connectivity between providers and payers. As a result of this market shift, plans are seeking new types of information from providers and want to automate the exchange of data to facilitate the new payment models.

The Availity report is based on interviews that Porter Research recently conducted with 39 health insurers. These plans, which include payers of different sizes and types -- including not-for-profit, for-profit, commercial, Blue Cross Blue Shield and Medicare Advantage plans -- are representative of the marketplace, said Brian Kagel, director of business intelligence for Availity, in an interview with InformationWeek Healthcare.

Value-based payment models reward healthcare providers for meeting quality and efficiency goals, rather than for simply delivering a service, as in fee-for-service models. Among the value-based payment models referenced in the report are accountable care organizations, patient-centered medical homes, payment for coordination, pay for performance and bundled payments.

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Eighty-two percent of the respondents said that development of new payment models was a "major priority" for their organizations. Twenty percent said that these models support more than half of their business today; 40% predicted that that will be the case in three years; and 60% said that it will happen in five years.

Currently, 75% of the respondents are focusing their value-based payment initiatives on employer group plans, and 54% on Medicare Advantage plans.

Ninety percent of respondents agreed they need new kinds of data from providers and must automate the exchange of that information. Nearly three-quarters of the insurance executives said their companies planned to implement this automation within the next 12 to 18 months. Right now, however, 90% of the plans use a hybrid automated/manual process, and fewer than 50% have real-time automation capabilities, the report said.

The new kinds of data that the health plans seek include information in electronic health records (EHRs), lab systems and hospital admission-discharge-transfer (ADT) systems, said Kagel. Payers want this data, which isn't included in claims, "to give them a broader perspective of the patients, to understand the patient's history and where there might be [cost] risks," he said. They can also apply analytics to the data for care-management purposes, he added.

In addition, he noted, the plans want to use the same data to measure the performance of individual providers and groups. "They want to know what care was delivered and what were the outcomes of care -- whether prospectively, making sure they're focusing on the right patients and delivering preventive care more holistically, or retrospectively, looking at the quality measures and quality reporting within those value-based models."

From a plan perspective, it's important to automate the exchange of this information so that fewer people are needed to collect it and so that it can be gathered on entire populations. And it needs to be collected in near real time, Kagel said, so that the plans can be apprised of what's happening with members in the healthcare system.

"Take census reports in a hospital. In many cases, those are phoned or faxed in once a day or periodically from a hospital to a payer. Through a real-time connection to a hospital system, we can do it patient-by-patient, as it occurs, with richer information."

However, it will be some time before most plans have this capability, Availity CEO Russ Thomas told InformationWeek Healthcare. "We see a transitional process for the health plans. For example, we're implementing portal capabilities within the plan's care management system to allow real-time viewing of information. Where we think that will ultimately go is integrating that same information into their backend system for adjudication [of payments] and authorization [of tests and procedures]. Right now, we're seeing interim steps as plans upgrade their technological capabilities."

In the long run, he said, plans should be able to use the clinical data they pull from EHRs and other sources to help calculate value-based payments. "It's not going to happen overnight, and it might not happen in the next year or two. But as plans enter risk-based relationships with their provider groups, they have to find ways to automate the assessment and calculation of those risk payments so providers can get paid as quickly as possible."

Availity recently announced a three-way deal with Florida Blue and EHR vendor Greenway that will enable Greenway users to receive claims-based patient summaries from Florida Blue and send clinical data back to the plan. According to Availity, this is the first bidirectional exchange of clinical information between a health plan and its providers.