Improving payer-provider collaboration to improve patient care

The relationship between payers and providers has traditionally been a bit rocky, with payers judging providers based on the claims they received.

Those days are gone. Payers and providers are now sharing common goals such as improving clinical outcomes, improving financial outcomes, and improving overall patient care and experience.

Payers are changing reimbursement methodologies, being transparent about provider quality measures, and engaging with providers in what they are trying to do from a quality perspective. Providers are sharing clinical data with payers allowing for tighter coordination of care management, case management, and utilization management. But this evolution in reimbursement and clinical collaboration and coordination has required significant investment in systems and technologies to support the alignment of payer-provider efforts. This article chronicles one leading health insurer's journey.

The health plan has become nationally recognized for its value partnership programs and collaborative quality incentives. The plan has developed one of the largest and most successful physician incentive and Patient Centered Medical Home (PCMH) programs in the U.S. The initiative has brought together more than 40 provider organizations, representing 19,000+ primary care and specialty physicians. These physicians have participated in initiatives aimed at improving care delivery through data collection/sharing and closer provider-payer collaboration in patient care.

The insurer has launched more than 20 physician incentive programs, ranging from service-focused delivery such as radiology utilization management to clinical-focused services such as evidence-based care tracking. By promoting a value-based, PCMH model, the organization has made significant progress in improving care quality, lowering costs and increasing patient satisfaction by incentivizing physicians to focus on the total health and wellness of each patient.

While the programs were tremendously successful, the health insurer's ability to grow, evolve and expand them had become hindered by its inability to efficiently collect and analyze data for various initiatives. A large amount of analyst's time was being consumed aggregating and enriching data from a number of sources rather than conducting meaningful analysis, researching/evaluating new opportunities, and implementing initiatives. The insurer needed a more robust clinical analytics platform, so it embarked on a nine-month effort to build a single clinical programs and medical informatics data mart. The goal was to consolidate the insurer's vast amount of core data related to its incentive programs and provide streamlined, accurate analytics capabilities and reports.

The data mart pulled information from disparate sources into a consolidated format and automated advanced methods for data scientists to identify and better understand the relationships between concepts such as a unique person, care relationships and encounters over a person's lifetime, etc.

Since its initial launch, the clinical programs/medical informatics data mart has evolved into a much larger and enabling platform for the insurer. The data mart has been integrated with external engines like the Healthcare Effectiveness Data and Information Set (HEDIS) to provide industry standard best practice metrics for measuring a person's health risks and the quality of care received. Efforts were expanded to include customer and ad hoc wellness and care management analytics and reporting.

Additionally, the insurer and its partner implemented STARS Ratings and Provider Quality reporting for improving provider quality ratings, National Committee for Quality Assurance (NCQA) accreditation levels and ultimately financial performance. The analytics team designed and implemented a data integration process that included major elements like:

  • Integration with external engines for diagnosis gaps, physician efficiency comparisons, chronic disease identification and more
  • Design and implementation of an analytics model to derive gaps in care and treatment opportunities based on HEDIS metrics
  • Establishment of data feeds in the Provider Portal for sharing identified gaps in care and treatment opportunities and diagnosis gaps with providers

This was followed by two projects aimed at using advanced analytics to control costs: Evidence-Based Care Reports (EBCR) and Transition of Care.

By tracking EBCRs, the insurer wanted to encourage best-practice behaviors among physicians by promoting awareness and use of evidence-based medicine guidelines into their daily practices. In support of this initiative, the date analytics platform became the foundation for providing EBCR data that would allow provider and physician organizations to compare evidence-based care usage against applicable benchmarks, develop processes for identifying and reducing gaps in care, and ultimately qualify for incentive payments based on their overall performance and improvement over time.

Here are some highlights of the EBCR dashboards/reports and metrics produced for physician organizations:

  • Overall EBCR Score
  • Overall EBCR improvement compared to 12 months prior
  • Overall improvement based on the evaluation of the clinical topics such as Diabetes, Asthma/COPD, Medication Management, Adult and Child/Adolescent Prevention
  • Effectiveness Ratings – effectiveness in reducing gaps in care, overall performance toward the benchmark

The insurer's Transition of Care Initiative was aimed at improving the planning and communication between inpatient and outpatient facilities and preventing inpatient hospital readmissions. As a result of the initial work on the clinical analytics platform, the insurer was able to produce a variety of dashboards and reports that were not available previously. Reports identifying the number and frequency of inpatient discharges and readmissions – plus much more – are now available to them.

In all, this insurer has made great progress toward establishing a competitive advantage in the area of data analytics and the upstream/downstream processes it enables.

Since launching its data mart, the insurer has:

  • Developed an approach to optimizing the selection of patients targeted for outreach for specific wellness, disease management, case management, and care transitions programs
  • Developed an approach to coordinating the care management services delivered by health plan personnel and by provider-based care managers
  • Developed complex physician organization and Accountable Care Organization (ACO) dashboards and reports for various organizational uses

In planning the data mart, the insurer wisely started at the beginning — where data becomes information. The organization has been able to leverage its analytics platform to significantly improve the collaboration between payers and providers. This is one payer that's well-positioned to meet the challenges of ACA and the delivery of value-based care.

Summary of Data Mart Benefits:

NCQA Accreditation/HEDIS

  • Hundreds of millions of records submitted to the HEDIS Engine for NCQA Accreditation with a 99.99% data acceptance rate.

Performance Improvements

  • Monthly PCP Attribution and encounter processes that used to take weeks and months to run now take hours
  • Monthly pharmacy, facility, and professional claims extracts that used to take hours now take minutes
  • Processes to create Pharmacy, Inpatient, and Emergency Department dashboards are 10-15x more efficient
  • EBC (Evidence Based Care) metrics for providers that used to take weeks to produce can now be run/created in under 30 minutes

Other Platform Benefits

  • Created a single platform for all clinical analytics and processes
    • Over 10,000 reports delivered annually
    • Overall analytic capacity has doubled for each analyst on staff
      • New platform drastically decreases data aggregation and integration efforts that analysts need to do to prepare their data sets for analytics.



Yunus Burhani is Senior Architect at X by 2 in metro Detroit, a technology consultancy focused on the practice of architecture for the insurance and healthcare industries.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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