Taming Time and Moving Healthcare Data

A New York-based startup health plan is on a quest to achieve one of the most elusive goals in healthcare insurance: processing information among payers, providers, and patients in real time.

A small company based in New York is tackling one of the biggest dimensions of health insurance: time.

"The traditional communication channels between providers and payers have been antiquated," Mario Schlosser, co-founder and co-CEO of New York-based Oscar Health Insurance, told me last week.

Oscar, launched in fall 2013 and marketed to individuals and their families through a website designed for ease of use, is striving to make a technological leap to real-time sharing of healthcare data. While the claims adjudication process remains a daunting time barrier, Oscar is automating as many other processes as possible to establish real-time communications between payers, providers, and patients.

Schlosser says the key to taming time is marrying long-term payer data such as medication history with provider-generated clinical data. "Lack of information flow in the healthcare system impedes service and slows the process down. It could be so much easier. It generally amazes me, the 10- to 20-year-old technology you find in healthcare."

Oscar's website helps health plan members gain easy access to physicians through an up-to-date and searchable provider registry. "We want to know which doctors have open panels," Schlosser says.

On the health plan's back end, technology makes it easier for Oscar to process claims and perform other administrative functions through automated workflows.

For the provider network, technology is helping to fuel a heightened level of cooperation, he says. "We constantly think about how we can get closer to providers."

Oscar has established an active and information-rich "feedback loop" with providers through a partnership with Boston-based NaviNet Inc. "We share eligibility in real-time, including deductible status and co-pay costs. That enables the doctor, very quickly, to get the pulse on the member's coverage status," Schlosser explains. "Providers spend a lot of time and effort to collect bills. Collection costs have increased. A doctor needs eligibility information in real-time. Then the doctor can simplify his workflows around care."

Sharing information with providers broadly and quickly creates a "virtuous cycle," Schlosser told me. "Doctors spend more time with patients. If we make life easier for the doctor… the doctor can spend more time with the patient than with us. If Oscar patients are happier with the care facilitated by us, then we can keep the cycle going."

Frank Ingari, NaviNet's CEO, says the Boston technology company has forged a powerful bond with Oscar by focusing its healthcare IT collaboration on providers. "The network is the organizing model," he says.

Earlier this month, Oscar chose NaviNet Open to serve as a payer-provider communications platform with real-time capabilities. Ingari says a prime objective of the platform, which includes a set of network services as well as reimbursement-related and clinical applications, is to establish a "robust way" for providers and payers to exchange information. "Healthcare has been very, very much lagging in providing secure communication."

Oscar is using NaviNet's platform to create a pair of communication channels with providers. An "interactive channel" includes the triggering of information exchanges whenever an Oscar health plan member experiences a healthcare event such as an emergency room visit. "The event will trigger medical document exchange in real-time," he says, noting that access to payer information and clinical histories gives physicians "guidance in the moment."

Ingari calls the platform's other communication channel a "clinical campaign" that features scheduled and targeted releases of information to providers. This set of information does not have to be triggered in real-time, but timeliness is essential to help physicians hit quality benchmarks and "push out the patients who are highly in need of an exam."

"In both cases, the product works bi-dimensionally. Payers and providers can be pushing and pulling information."

Oscar has an accurate directory of "everyone who is an active sender or receiver of information;" clinical documents are exchanged automatically, often with network alerts about clinical or financial developments in a patient's records; and the sharing of information in real-time includes "management of the preferences of a care team," Ingari says.

Everything that happens in the network happens in real-time, with one exception.

"To enable real-time payment, you have to have real-time adjudication. Today, it's a rare capability in healthcare, but it can be done. … Oscar is moving in that direction."

Mindset is also a problem, Ingari says, noting that a historical barrier must be cleared before processing a patient's healthcare transactions becomes as instantaneous as buying groceries with a debit card.

"We got exactly what we designed," he says of the historically adversarial relationship between payers and providers, "payers who have been ignorant about quality of care, and providers who haven't cared about cost. You need communication of information across that payer-provider barrier. We need evidence-based guidance. We know that can deliver tremendous value, but we have a mountain to climb."

"We're coming to a time when it's all about execution," he says. "You're being rewarded now for cooperating with providers, not exploiting your providers. That's a big change."