Megatrend Spotting: Health Plan Role of Having “Best Data About YOUR Medical Conditions” is Up for Grabs

Who has the most comprehensive data about YOUR clinical conditions?

For most people, the answer today is “your health plan”, but it’s not at all clear that health plans will continue to have this role in the future.

As physicians and hospitals adopt EHRs, it’s foreseeable that clinical data about patients will be far more available and accessible.

Will patient data become:

• A jockeying point for control and business advantage between health plans and care providers,
• A collaborative opportunity to optimize clinical care and care coordination, or
• Both?

Background

For most U.S. citizens, health plan claims data comprises the most comprehensive data about an individual person’s recent medical history.

Claims data is far from perfect, but still it’s the best data that’s been out there. Its a second-rate proxy for clinical data, but to-date clinical data mostly has been “frozen” and inaccessible in care providers’ paper charts.

The primary purpose for acquiring claims data is for payers to pay care providers — to have sufficient information on which to pay a “claim” (e.g., doctor visit, lab test, prescription) submitted by a care provider.

Health plans also use claims data for a number of secondary purposes, for example:

• Risk stratification and predictive modeling. Aggregated claims data provides useful information for selecting and managing patients in disease/care management programs.
• Populating consumers’ personal health records (PHRs).
• Creating a payer-based health record for use by care providers.

One of the predictable responses to HITECH is that a vast amount of clinical information will be entering the data stream.

Advantages and Challenges of Claims Data

The National Academy for State Health Policy (NASHP) recently released an issue brief entitled Evaluating the Patient Centered Medical Home: Potential and Limitations of Claims-Based Data. While the primary focus of the brief is a research perspective on the medial home, it’s also good primer on claims data.

The NASHP brief lists advantages and challenges related to claims data.

Advantages

• Claims based data may allow the ability to look back in time
• Claims data can point to gaps in care
• Claims data allows researchers to observe all billed care
• Claims data benefit from availability of nationally endorsed performance measure specifications
• Claims data are relatively inexpensive to obtain
• Claims data may offer the ability to assess disparities based on race, ethnicity, or socioeconomic status 

Challenges

• Obtaining claims data often requires negotiating data use agreements with health plans and the Centers for Medicare and Medicaid Services (CMS)
• There is a time lag between the delivery of care and the availability of claims data pertaining to that care
• Relying on claims data makes it difficult to attribute data to study practices
• Missing data about individual services or groups of people presents another challenge for using claims data to evaluate medical home initiatives, particularly for researchers tracking care of the uninsured.

More Questions Than Answers

There are many uncertainties:

• Will the role of having “best data about YOUR medical conditions” become a battle for control and/or an opportunity for collaboration?
• Will clinical data supplant or complement claims data?
• Will claims data fade into the sunset? For example, if Accountable Care Organizations become prominent, health plans would pay providers prospective, risk-adjusted payments – ergo, no need to pay individual claims or gather claims data.
• What would happen if  “patient control” over data become the law of the land instead of lip service? Current privacy laws are ambiguous. Who would patients trust with their clinical data? Would you choose to share your clinical data with your health plan?
• Ultimately, will health plans, care providers, or even patients themselves have the “best data about YOUR medical conditions”?

 Implications

Will having the most comprehensive or best clinical data be sufficient to provide optimal care coordination?

No….having lots of data or even the “best” data is not sufficient to optimize care and care coordination.

However, having the best data is foundational for optimal clinical care and care coordination.

It’s not clear who’ll have the best data, but it is clear that health plans are no longer heir apparent to their King-of-the-Hill role of best data about YOUR clinical conditions  – the role is up for grabs.