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The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


Sharing Quality Insights With Providers


By Michael L. Taylor/Tuesday, August 18, 2015

BlueCross/Blue Shield of Illinois (BCBSIL) recently announced a new data sharing arrangement with the DuPage Medical Group, a large independently owned physician medical group in the Chicago area.  This arrangement calls for BCBSIL to share its medical claims and (unnamed) quality data with physicians of the DuPage Medical Group. These data will help the physicians better understand the healthcare services their patients are receiving outside the DuPage clinic walls, including the quantity and quality of care their patients are receiving from non-DuPage physicians.

This information is becoming more important to physicians as their reimbursement for services provided is increasingly tied to patient outcomes. The Blues organization also announced their goal of having 75% of their Illinois market to be paid on the basis of improved quality and lower costs within the next 5 years. This trend has been driven by the Center for Medicare and Medicaid Services (CMS), with HHS Secretary Burwell announcing the 2018 CMS target of 50% of payments based on value, and 95% of fee for service payments having a quality component as part of the payment.

We are likely to see many other arrangements similar to the BCBSI deal in the commercial market over the coming months and years. The country is gradually realizing that fee for service payment arrangements become an incentive to provide more care, while value based payment models incent higher quality care.

Rewarding higher quality care and penalizing poorer quality care is a step in the right direction, and for certain elements of care, quality can be readily measured. For example, for most common surgical procedures, standards have been developed to measure complications, length of stay, hospital-induced infections, mortality and other discrete endpoints. It may not be as straightforward to measure quality of care in the primary care settings, but quality can be measured.

An interesting article published in 2012 in The New England Journal of Medicine offered a framework for measuring system-related quality of care. The authors suggested 6 domains of quality that could be measured:

  1. Patient safety
  2. Patient and caregiver-centered experiences and outcomes
  3. Care coordination
  4. Clinical care
  5. Population and community health
  6. Efficiency and cost reduction

This framework may be well suited to measure the effectiveness and quality of care being delivered in the primary care setting, and these efforts need to be supported. Hopefully this BCBSIL and DuPage Medical Group partnership will spur other large carriers to try similar arrangements with hospitals and physicians. Combining cost metrics with quality metrics can deliver the type of transparency that is lacking in today’s fee for service world. The payer community has been asking for this type of transparency, and consumers are now asking for the same information.

I’m hopeful the metrics agreed upon will be shared publicly.  It will be interesting to follow this new arrangement over time to see if the quality metrics are robust, and if patient care actually improves.

Michael L. Taylor, MD, FACP
Chief Medical Officer

 


Shifting the Data-Sharing Mindset for the At-Risk Healthcare Environment


By Larry Yuhasz/Thursday, November 14, 2013
Larry Yuhasz imageThe shift from fee-for-service (FFS) to at-risk reimbursement also represents a shift from siloed data sources and facilities to physician-driven networks that need to be connected with patient-centric decision support and work flow applications. In the FFS world, health systems and health plans often thought of patient data as a strategic asset to help recruit and retain both physicians and patients to their networks and services. Yet, in the at-risk world, the more data available about the patient, the better the ability to manage risk and coordinate care. The change in mindset from controlling patient data to allowing it to flow freely (albeit, securely) across networks is a radical transformation in the U.S. healthcare system. The three key barriers to overcome are business model, proprietary data formats and governance.

At the business model level, as health systems, providers, and payers form new at-risk arrangements, they need to under gird those arrangements with the relevant flow of administrative and clinical data to manage performance and risk. Health plans that have been reticent to share claims data need to shift gears both culturally and operationally to help the new provider-driven networks understand costs.

In terms of format, the Federal government has been trying to stimulate interoperability standards through the ARRA HITECH roll out, but many vendors (particularly EMR vendors) have been fighting back to defend their proprietary data formats. As the volume of at-risk contracts grows, new at-risk entities will not be able to function without some form of interoperable gateway to share and receive patient data. So that means that EMR customers will be the ones to request and implement interoperable gateways from their vendors. And if they continue to resist, there is a new generation of interoperability platform vendors that will fill the need.

Finally, from a legal perspective, no one entity actually “owns” the patient data. The patient owns his/her own data. Yet this creates a quagmire of governance models that is bogged down in consent management policy and privacy mechanisms. If patients do not allow an at-risk network to see their data, the network cannot optimize performance. So we may see a new market dynamic whereby network participation requires upfront patient consent to data sharing (an opt-out consent model).

Larry Yuhasz
Director for Strategy and Business Development

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