Some leaders in the health IT space have pointed out that payers, not providers, stand to profit more from the health IT buildout than the doctors using their new electronic health record (EHR) systems — some even calling for payers to pitch in and help fund health information exchanges (HIE). Many providers, on the other hand, are wary of acquiring patient data from payers — wary because providers know that the payers’ bottom line and what’s best for the patient don’t always jibe.
Sometimes, however, a payer has a more complete picture of a patient’s health, because it’s collected information from all of the patient’s care providers — and that can include treatments, labs, prescriptions and other pieces of data that originate away from a doc’s office. Some patients have their own case managers with the payers.
So, what’s going to get them to play together nicely in the IT sandbox? We put that question to Scott Storrer, president and CEO of MEDecision Inc., a software company in Wayne, Pa., that makes applications for payers and HIEs. His company announced a new case-management module for payers of behavioral health providers that eventually will be able to port real-time “clinical summaries” of patient data into provider EHR systems, along with recommendations for treatment based on evidence-based guidelines that the payer endorses.
Storrer thinks that ultimately, private payers will follow the lead of the Centers for Medicare & Medicaid Services (CMS) — which is often the case in the industry — in making quality of care a priority, and setting up incentives for doctors to make it their priority too. If they can stick to that agenda and pour data into EHR systems, doctors and their provider brethren may end up learning to trust payers, reaping the fruits of the patient data that payers are collecting already.
“Once they validate that these summaries are truly based in evidence-based medicine, it drives a great degree of comfort with them,” Storrer said, referring to MEDecision’s physician focus-group testing. “All of these clinical summaries are there to be used as guideposts; they are not mandates by the payers … [but] if you are following, essentially, the medical management procedures from a payer, and you have the ability to generate more positive outcomes vis-à-vis your peer physician in your region, you will qualify for a higher degree of reimbursement from the payer,” at least in the pay-for-performance programs already popular among some payers. The meaningful use rules, of course, constitute the biggest-ever pay-for-performance program health care’s ever seen.
Storrer thinks that analyzing patient data and comparing it to evidence-based rules will be the common ground payers and providers will eventually find. It’s one way to get payers more involved in health information exchange. Whether or not docs and insurers and patients will all learn to trust each other is a whole different discussion, but this one is a start.