Waiting for Payers on Healthcare Integration

Waiting for Payers on Healthcare Integration

In a complex healthcare industry trying to adjust to increased regulations and political mandates, price pressures, and consumer demands, integration is important. The old model of a cottage industry in which each component operates independently as it wishes is no longer viable.

The industry needs greater integration. One type – strategic and operational integration – works within a greater healthcare organization. But there is another type – electronic integration – that is necessary within and between organizations to speed end-to-end treatment, reduce errors, and gain efficiency.

That concept is at the basis of the electronic healthcare record part of the Affordable Care Act and other efforts like healthcare information exchanges, or HIEs. Medical personnel and patients could gain access to patient information and records as necessary instead of waiting for copies of paper data and imaging films. And yet, there has been a major disconnect according to a report in the Journal of the American Medical Informatics Association:

We found a large gap between payers’ vision of what optimal HIE should be and the current approach to HIE in the United States. Notably, payers sought to be active participants in HIE efforts – both providing claims data and accessing clinical data to support payer HIE use cases. Instead, payers were often asked by HIE efforts only to provide financial support without the option to participate in data exchange, or, when given the option, their data needs were secondary to those of providers.

HIE is important because it could facilitate the exchange of test results, examinations, and other data in a more efficient way. Get the right information to the right place at the right time and you’ve reduced the need for duplicated tests and procedures. That is why providers have been heavily involved in such efforts.

According to researchers from the University of Michigan in Ann Arbor, there are far bigger benefits that could be possible. More complete patient information could help more fully eliminate redundant or avoidable work. That is why the involvement of payers is crucial. They often are the nexus of information about a patient because all the individual reports and bills come in to them.

However, payers have not been heavily involved and, as a result, have not seen in designs what they think is necessary for them. That includes the following:

  • a single network, or single-point access to a network-of-networks rather than current ad hoc arrangements;
  • broad access to clinical data and the ability to contribute administrative data;
  • restraint from treating data as a competitive advantage by either payers or providers;
  • financial contribution by payers in proportion to the value they receive;
  • and a triple aim of improving care, improving the health of populations, and reducing per-capita cost of healthcare.

Until providers and payers can establish middle ground and full cooperation, both in paying for the systems and ensuring that their needs are met, HIE is unlikely to make significant advancement and the overall healthcare system will continue to suffer.

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