Stakeholders say data sharing is critical to lowering healthcare costs

Witnesses tell Senate committee that patients need access to transparent price, quality information.

If the United States is going to rein in the high costs of healthcare, the industry must do a better job of sharing data with patients and among other stakeholders.

That’s the contention of Sean Cavanaugh, chief administrative officer for tech start-up Aledade, who previously served as the director of the Center for Medicare and deputy director of the Center for Medicare and Medicaid Innovation.

“Surprise billing in particular occurs because of a market failure—patients don’t have the time or the information necessary to shop to avoid these bills,” Cavanaugh testified on Tuesday before the Senate health committee. “We applaud this committee’s willingness to take on this issue and your willingness to consider multiple solutions and put patients’ interests first.”

Last month, Senate health committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.) released the Lower Health Care Costs Act of 2019, draft legislation to help tackle the problem of surprise billing.

The proposed bill protects patients from surprise bills, or out-of-network cost-sharing, and requires providers and health plans to give patients good faith estimates of their expected out-of-pocket costs for specific healthcare services—and any other services that could reasonably be provided—within 48 hours of a request.

“Meaningful improvements in all of the areas included in your legislation—including prescription drug prices, surprise billing and improved public health—all require better access to and flow of healthcare data,” testified Frederick Isasi, executive director of Families USA, a nonprofit organization dedicated to high-quality affordable care for all Americans. “Today, healthcare costs and measures of quality and effectiveness are often inaccessible and nearly impossible to share.”

Also See: Free flow of data, price info is what healthcare needs

“Consumers face many barriers to being informed purchasers of healthcare when they do not have access to price and quality information in the healthcare system,” added Isasi. “We also believe that it is critical to ensure that healthcare providers, payers, researchers and policymakers have access to underlying cost and quality data in order to make informed and effective healthcare payment and delivery system policies.”

To address the problem, the committee’s draft legislation bans gag clauses in contracts between providers and health plans that prevent enrollees, plan sponsors or referring providers from seeing cost and quality data on providers. It also bans gag clauses in contracts between providers and health insurance plans that prevent plan sponsors from accessing de-identified claims data that could be shared—under HIPAA business associate agreements—with third parties for plan administration and quality improvement purposes.

“By banning gag clauses, Congress can prohibit dominant providers from concealing the price and quality of the care delivered by health systems; this is information about the people’s healthcare, and patients and their representatives—such as employers—ought to know it,” said Cavanaugh.

He also testified in support of all-payer claims databases, which he contends must be leveraged to truly understand healthcare market dynamics.

“For many years, studies of the American healthcare system have relied solely on Medicare claims data—this is problematic, Medicare is very different than the private insurance sector and the patients are very different as well,” observed Cavanaugh. “Many anti-competitive behaviors have been exposed by studies using multi-payer claims databases, such as the one administered by the Health Care Cost Institute.”

Tom Nickels, executive vice president of the American Hospital Association, noted that the proposed Lower Health Care Costs Act of 2019 would create a national all-payer claims database (APCD) and provide grants to states to encourage implementation of their own APCDs.

“These databases are intended to promote transparency by requiring insurers to submit claims data, which are made available to researchers and policymakers for use in analysis,” Nickels testified. “They also are intended to enable hospitals, healthcare providers and communities to benchmark their performance against that of others.”

While the AHA recognizes the potential of APCDs to drive quality improvements and cost containment, Nickels cautioned that the privacy and security of the data must be protected and that the data released must be presented in its full context.

“Should the committee move forward with this effort, we recommend that the privacy and security requirements for receiving, storing and transmitting data be strengthened by: requiring privacy and security training for staff and authorized users, including federal agency users; and requiring the APCD contractor in the required annual report to describe the privacy and security standards around receiving, accessing, storing and transmitting data, as well as any privacy or security incidents that have occurred,” Nickels said in his testimony.

According to Nickels, the AHA also recommends that “the data released by the APCD be put in context, as claims data are highly complex and do not always present a full picture of the care and services offered by providers,” noting that “to draw meaningful conclusions from these data, it is important to understand what is and is not included in the data,” which “means having a clear understanding of any limitations or gaps in the data, as well as understanding what other factors not represented in the data may impact the findings of analyses.”

Benedic Ippolito, a research fellow at the American Enterprise Institute, testified in support of the Senate health committee’s efforts to further increase transparency by designating a nongovernmental, nonprofit entity to use de-identified healthcare claims data from self-insured plans, Medicare and participating states to help patients, providers, academic researchers and plan sponsors to better understand the cost and quality of care.

“Assembling and disseminating this kind of information is crucial for addressing the long-term healthcare cost growth,” said Ippolito in his testimony.

The AHA has asked that the governance body developed to oversee the APCDs “include dedicated seats for healthcare providers who could play a valuable role in translating the experience of providing care, what occurs in a clinical setting and what is not captured in administrative claims data,” added Nickels.

To make provider markets more competitive, Cavanaugh called on Congress in future legislation to consider requiring hospitals to share patient-centric data.

“Medical and economic literature demonstrate that patients have fewer readmissions and other adverse outcomes when they see their (primary care physician) after discharge from the hospital,” he said in his testimony. “But independent physicians can provide this care only when they receive timely notification of the patient discharge. Aledade has encountered resistance from some hospitals in providing these data—even when we bear the cost of the interfacing and there is no technological barrier.”

Aledade, which is led by CEO and co-founder Farzad Mostashari, MD, former National Coordinator for Health IT, works with independent primary care practices in 24 states to create and run accountable care organizations. “At Aledade, that’s one of our big strategies—have our doctors visit the patients after discharge,” commented Cavanaugh.

He pointed out that CMS recently published rules requiring hospitals to share admission, discharge and transfer data. “We applaud this move, as it will greatly increase patient safety,” Cavanaugh added. “That the rules are needed at all is proof that maintaining a competitive environment requires vigilance.”

The CMS proposed rule requires—as part of the Medicare Conditions of Participation—that hospitals send electronic event notifications to another healthcare facility or to another community provider when a patient is admitted, discharged or transferred.

However, the AHA has previously stated that it does not support including electronic event notification as a condition of participation for Medicare and Medicaid.

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