Lynda Rowe is Senior Advisor, Value-Based Systems, for InterSystems. She provides guidance on alternative payment models, public sector, state Medicaid programs, and related areas. She has over 25 years of experience in information technology, mostly in healthcare technology consulting and operations.
Have you ever gone looking for a new healthcare provider? I have, and it fills me with dread.
First, it means a new relationship with someone who will be taking care of me and my health. Often it means that someone I have trusted is leaving and I need to find an adequate replacement. And as much as leaving an old provider is difficult, finding a new caregiver can be even harder. I usually start by asking someone I know, like another healthcare professional, for a recommendation or referral. But sometimes, it comes down to searching the “find a physician” site – the “provider directory” — of my favorite health system, or my health plan.
So I’ve done just that – I’ve gone to the site of a large academic medical center, searched for a PCP, and found a lot of options. However, the site doesn’t tell me if the provider I like is accepting new patients OR if they accept my insurance. My health plan’s website, has a great search function. But too often, the caregiver I’ve located on the health system site turns out to be in my insurance network, BUT, not accepting new patients.
I have been researching the issue of Provider Directories for almost 4 years now. What surprises me is that although this is a hot topic nationally, no one has fixed the problems. There has been talk about a national provider directory, and certainly there is the NPPES (National Plan and Provider Enumerations System) database managed by CMS which should contain some basic information about a provider, but the data there is not very accurate. Further, a national provider directory isn’t very practical.
I think the problem is twofold:
First, providers work locally; keeping their information up to date on a national level doesn’t really meet the needs of a patient in a particular geographic area. Maintaining that would be onerous. Furthermore, CMS doesn’t have any interest in maintaining data (nor does it have data) about a provider’s relationship with a local health plan.
Second, and more importantly – providers change their information all the time. Nationally, 25% of provider data changes annually. That’s a lot of change to keep up with.
Let me give you a specific example: One of my providers practices in an outpatient clinic associated with a large academic medical center. He sees patients at two locations and accepts a number of different insurance plans. However, once a week he practices at a Federally Qualified Health Center and accepts Medicaid at that location. That’s a lot of information for a given point in time and I know that his information changes a lot because I have been his patient for many years.
My point here is that this is not an easy problem to solve. This is another case where payers and providers need to collaborate, work together and make it easier for everyone including their patients. Provider Directories need to be maintained locally and both payers and providers need a good system for mastering their provider data.
If the provider or IDN has a Golden Record, a unified, mastered, single-source of truth, for their provider information, it:
helps patients find providers,
helps refer patients to in-network providers,
allows care team to be associated with patients, and even better –
provides good quality data to send to their payers.
For payers, a Provider Directory can:
manage data from their large provider network,
inform members how to find providers, and
streamline internal operations.
Not to mention, it helps payers avoid fines and penalties.
Finally, the new CMS interoperability rule requires certain government funded payers to make data from their provider directories available through FHIR APIs, and providers participating in Medicare to provide updated inform to the NPPES. Now is the time for organizations to find solutions that help them maintain a good, high quality provider directory. It would certainly make my life as a patient easier!
I recently read an article in New England Journal of Medicine (NEJM) Catalyst1 that showed that the alignment between providers and payers does not seem to be closing, despite the industry shift to value-based payment.
The survey, conducted among executives, clinical leaders, and clinicians, finds that three-quarters (77%) of respondents do not consider payers and providers aligned toward realizing improved value in care delivery. More than half (58%) feel their own organizations are not aligned. Moreover, only three percent of respondents say payers and providers are extremely or very aligned at the industry level.
According to this survey, this lack of alignment hampers integration of care and services and is a primary driver of our high healthcare costs. The study highlighted key areas where payers and providers should be able to collaborate or align along with the percentage of respondents who thought there was alignment:
Key Areas Where Payers and Providers Should Collaborate (% Aligned):
Quality 58% aligned
Patient/Member Experience 45% aligned
Care Coordination 37% aligned
Cost 33% aligned
Data for Decision Making 33% aligned
In some ways, I don’t find these results too surprising, given that there is still a lack of financial incentives between payers and providers. Despite all the talk about the shift to value-based payment, just under 30 percent of all health care payments in the US are tied to alternative payment models (APMs).2 This is a six percent increase over data collected the prior year — good progress, but lower than expected.
To look at the current data of APM adoption, the Healthcare Payment Learning and Action Network LAN APM Measurement Effort3 determined the following results for 2016 payments:
Alternative Payment Model (APM) 2016 Payments:
43% of health care dollars in Category 1 (e.g., traditional FFS or other legacy payments not linked to quality)
28% of health care dollars in Category 2 (e.g., pay-for-performance or care coordination fees)
29% of health care dollars in a composite of Categories 3 and 4 (e.g., shared savings, shared risk, bundled payment, or population based payments)
As another NEJM Catalyst article recently stated, many providers find themselves with a foot in two canoes — a very challenging place for the industry. As long as they continue to see consistent revenue in the fee-for-service model, there’s no burning platform for change.
However, herein lies the problem: if payers and providers are not aligned on the shift to shared risk and financial accountability, they also won’t be lined up to work together on quality, cost, and operational efficiency — that is, better care at a lower cost.
To succeed, we need to close the gaps. Many of the existing barriers stem from a history of misaligned goals and incentives and lack of transparency between organizations. As noted above, payers and providers are least aligned on leveraging data to make better decisions for system improvements, and that’s a solvable problem.
So what is the path forward to cross the chasm? Based on current trends, value-based care — although moving slowly — appears to be part of the new fabric of healthcare. As providers and payers continue to take on more shared risk, the alignment gaps will close. To achieve the outcomes we want, payers and providers will need to show more transparency, which requires two-way data sharing. My observation has been that, although barriers exist to providers sharing their data with payers, data needs to flow in both directions to get to a win-win scenario. Payers can help their provider network perform better against quality, cost, and utilization measures by sharing that information. Conversely, having access to clinical data will allow health plans to streamline some administrative processes such as pre-authorization and HEDIS/STARS reporting to drive cost and wasted time out of the system.
We have heard from our forward-leaning customers that two-way data sharing leads to success. The best outcome, however, will be better, more coordinated care for patients.