How payers and providers communicate: Q&A with NaviNet CEO Frank Ingari

Providers and payers interact constantly — online, by phone, and face to face. Huge volumes of information go back and forth between them, such as claims, eligibility and benefits inquiries, referral authorizations and lab data.

For decades, these communications were often characterized by antagonism and payers having an advantage with their computing power and data storage. But today, with the spread of EMRs and rise of value-based reimbursement, the dynamic seems to be growing more equal and collaborative.

For example, in explaining Anthem Blue Cross' investment in the massive Cal/Index project, which will put the EMR data of more than 9 million Californians into a single Health Information Exchange and promote payer-provider and provider-provider data sharing, Anthem Blue Cross President Mark Morgan said, "We believe that providers and plans must collaborate to ensure that Californians receive quality healthcare at a sustainably affordable price — and a fundamental component is sharing comprehensive patient information broadly and efficiently." 

Frank Ingari is president and CEO of health IT company NaviNet, which serves as an interactive healthcare network for payers and providers. Here, he weighed in on communication between providers and payers and discussed other trends with the provider-payer relationship.

Note: Interview has been edited for length and clarity.

Question: Communication between providers and payers is currently a one-way street. What trends are you seeing with that?

FI: Information sharing is really behind in healthcare, but changing fast for the better. Historically, the country had set up the system with a lot of built in structural antagonism, which was reflected in asymmetrical information assets and some really dysfunctional communication. Payers tended to have big volumes of information — claims, lab results, pharmacy benefits management data — while the pre-EMR provider side had little data. In that environment, payers tended to hoard and use the data for a competitive advantage during the contracting process, so information sharing was weak.

This is all changing now — big time. All the economic and regulatory forces of reform are rewarding more transparency and cooperation between the payer and provider. Another factor is more providers are gathering under the umbrella of a health system that has a system for communication. If a hospital acquires a primary care group, communication between the hospital staff and the PCP group should get better.

A third important factor is the coming of interoperability standards and some of the governmental support for that. Direct secure messaging is a good example. It hasn't spread as much as people want, but it has spread quite a ways and is pretty successful. Now providers in different systems can begin to communicate directly to each other via DSM or through an HIE. Provider-to-provider communication outside the same health system is still pretty weak, but the trends are going in the right direction for information exchange at the connectivity level — at the level of being able to move the information.

So the first problem is to establish connectivity at the network level. The second big problem in information exchange is not at the connectivity level. It's in the information itself. You have tremendous challenges for data exchange in terms of the need for common definitions of data. This is really hard because healthcare is so complex. There's so much terminology and so many people with a vested interest in one specific definition for a given data element or data set.

Q: What do the insurance mega-mergers mean for the future of competition between providers and payers?     

FI: The speculation so far has been based on largely conventional analysis that would apply to any industry. What you're seeing in the mainstream press are three generic drivers that apply to major mergers in any industry — scale, cost synergies and technology leverage.

Those are obviously correct, and raise fears that the major impact will be excessive leverage for the big three payers when negotiating with providers. But there is another factor specific to healthcare, which could be as important — the Medicare Advantage business. The growth in Medicare Advantage that's predicted in the next 20 years is huge, and payers are doubling down. I believe both Anthem and Aetna were looking for additional Medicare Advantage lives and skills.

This will have a big effect on providers and on payer-provider communication, because the business model you need to succeed in Medicare Advantage promotes collaboration. It promotes coordinated care. It promotes population health management. And it's likely to keep doing that as CMS changes the star ratings every single year.

Q: How are payers and providers exchanging information?

FI: According to IBM, 80 percent of healthcare data is so-called "unstructured" — it doesn't fit neatly into rows and columns. This data is incredibly important, but is exchanged in primitive fashion today when compared to the structured data found, for example, in a claim. Mountains of fax, snail mail, chart pulls that lead to foot-high piles of paper being driven across town — there is no other major industry still doing business this way.

This is our major focus at NaviNet. We have an information exchange product that allows for payers and providers to exchange these kinds of information bidirectionally while staying in compliance with HIPAA rules. This is not as simple as sending information directly to the doctor, who can't possibly handle all the data that relates to a patient, let alone a population. You want to communicate information to the right person in the support team, whether that's the front desk person who needs to schedule a lab test, a care coordinator or a social worker. This is particularly challenging in healthcare because a majority of doctors don't practice in the same place every day. We're building routing rules so I can match the patient, the assistant, the doctor and the location and get the right document to the right place at the right time with HIPAA [compliance].

Structured data, on the other hand, moves pretty well now, largely in the administrative domain. The X12 EDI standards handle the so-called HIPAA transactions where the provider transacts with the payer, for example to get authorization for a referral. One thing we're focusing on is connecting the clinical data to these well-grooved X12 pathways, for example injecting Care Gap information as part of a response to a provider's request for eligibility information.

Q: Any other trends you're seeing with providers and payers?

I see hospital systems partnering with payers in new ways that include the hospital being responsible for some of the things the payer used to be responsible for, and in turn for that, getting access to the risk and the upside reward as well. We see a lot of that, a traditional insurance company acting in an untraditional way.

We're seeing the big payers sitting down and saying, "What do you really want? Let's focus on what you really want, and maybe we can help you get there." We're seeing a lot of that in how dramatically payer-provider contracts are changing. You're seeing the distribution of risk, reward and functions, all in a much more partnering style.




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