Health plans in the catbird seat for pushing provider interoperability

Health plans are in a central position to improve interoperability, especially through the use of payment models that require certain standards for how providers exchange data.

The growing shift to value-based care can be the impetus for the push to data exchange, says Vindell Washington, MD, executive vice president and chief medical officer of Blue Cross and Blue Shield of Louisiana (BCBSLA) and former National Coordinator for Health IT.

“In the traditional fee-for-service system, the financial incentive was for providers to run tests or do extra services to get more patient data because they could be reimbursed for it,” says Washington, a former National Coordinator for Health IT within the federal government.

“With all the electronic data exchange methods we have now, insurers can change the financial incentive to promote information sharing and make it more cost effective for a provider to get information from us or from another health system, even if it's a competing health system,” he contends.

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Vindell Washington, MD

Patients get care from different providers, all while covered by the same insurer. This puts health plans in a unique position to encourage information-sharing, according to Washington, one of the authors on a paper published May 9 in the New England Journal of Medicine’s Catalyst, titled, “Promoting Interoperability: Rules for Commercial Payers.”

“We view interoperability as a business imperative for enhancing value in healthcare, such as through value-based purchasing,” say Washington, and his fellow co-authors Craig Samitt, president and CEO of Blue Cross and Blue Shield of Minnesota; Peter Pronovost, chief clinical transformation officer of University Hospitals; and Claire Wang, vice president for research, evaluation and policy at New York Academy of Medicine.

Health plans are motivated to achieve interoperability for a handful of reasons, authors of the article say. These include the pursuit of quality, safety and value of care; in addition to a interest in population health management and value-based care. Payers are already spending a great deal of money to maintain data and data exchange interfaces with their network of providers—why not take it a step further and require what it takes to make data interoperable, the authors ask.

People think that technology vendors, providers and regulators as the main bodies driving interoperability, but the truth is most commercial payers are already in the business of influencing interoperability, say Washington and his colleagues.

Through data exchange requirements found in contractual agreements, payers are laying the foundation for data sharing, file formats, field definitions, privacy, security and the reporting time frame. For example, BCBSLA requires that providers seeking to participate in its value-based payment program submit member clinical data in the format recognized by the Office of the National Coordinator for Health Information Technology (ONC). BCBSLA also requires providers to follow Department of Health and Human Services privacy standards, Washington says.

“Information sharing is good for everyone in the healthcare system—patients, providers and payers,” according to Washington. “It spurs innovation and it lets us develop targeted interventions to keep the community well and help people who have serious health needs.”

Washington, an emergency medicine physician, joined Blue Cross in 2017.

The Catalyst article can be found here.

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