Historically, health insurers have relied on one form of patient data, while providers operated in a different world.
Because it lines up with how they do business, health insurance companies have focused on analyzing patient care using claims data. Providers, of course, are far more focused on the contents of medical records, which offer a depth process and decision-making-related data that doesn’t show up in a claim.
However, over time both sides of come to realize that they need to speak in each other’s data language more fluently. In particular, providers are more likely to be successful at value-driven care if they can reap the benefits of both clinical and initiative/claims data.
In that spirit, health plan operator Health Care Service Corporation has struck a deal with Epic in which the two will allow providers using its EHR to engage in two-way information change. HCSC operates health plans in Illinois, Montana, New Mexico, Oklahoma and Texas, and has almost 16 million members across the five states.
Providers who use the new Payer Platform will be able to review patient data such as medical records, emergency department visits, diagnostic evaluations and lab results in addition to claims data. While the announcement doesn’t say so specifically, it seems likely that this will give providers visibility into medical records they would not have seen otherwise.
Given 250 million individuals worldwide have a medical record with Epic, and that a large percentage of hospitals have adopted an Epic system, it seems likely that the EHR vendor will be able to make a successful pitch to other health insurance organizations. Such future deals would further lock providers into the Epic proprietary technology world.
Now, of course, neither the HCSC nor Epic are describing the agreement this way. The two are selling it as a powerful step forward in dealing with some painful problems providers currently face. For example, the two argue that the new Payer Platform will help providers obtain prior authorizations, a very nice result if they can actually pull it off.
The partners also argue that by using the Payor Platform, providers will be able to create more effective care management strategies and help patients make better choices, ideally saving money in the process.
The truth is, though, it’s far from clear whether the portal can actually live up to the hype. Call me jaded, but it seems to me that I’ve seen countless announcements about technologies and processes which could make prior authorization easier, but few seem to pan out. (For example, I haven’t yet heard anything more about the Fast Prior Authorization Technology Highway initiative since it was announced in January by a group including health plan industry trade group America’s Health Insurance Plans.)
After all, at least over the short term, it’s not in health plans’ interests to make it easier for patients to get care.
And what about the wonderful benefits this data fluidity cab potentially provide in improving the process of care?
If having free access to claims data was sufficient to help providers transform healthcare – and what else do health plans have to offer that its peers don’t? — we would’ve heard more about this a long time ago. In reality, while providers can theoretically include claims data in their big data analytics efforts, doing so calls for extra work that might or might not be justified by the potential results.
I guess what I’m trying to say here is that while providers may well get some benefits of having greater access to patient medical records created outside of their institution, the other claims the two partners make seem speculative at best.