The healthcare industry continues to shift towards risk-based payment models that reward providers for lower-cost and higher-quality care. During HIMSS16, many education sessions were focused on new payment models and utilizing population health technologies to execute the strategy.
With these new models, both providers and payers are equally incented to be successful. The following example uses fictitious numbers to help frame an example of how this can be achieved:
Patient A has a stroke. In a fee-for-services payment model, the total cost of care for the entire episode might add up to $150,000. But, in an approach using population health technologies, let’s assume there was early awareness that a stroke was happening, followed up by diligent rehab routines with triggers and patient reminders. In this case, the total cost of the episode was only $100,000. Depending on how the savings is shared, the provider might get half of the benefit, which would be $25,000. The payer also spends $25,000 less while losing no revenue in premiums.
In the new payment models, both payer and provider win by managing the episode of care in a more efficient way. This incents payers and providers alike to share data so that they can both be involved to keep the population informed and follow-up on specific scenarios to avoid readmissions. In the specific case above, a payer might be able to determine which patients are stroke candidates and send them bits of information on what to look for and what to do in the event of a stroke.
Two HIEs at HIMSS16 presented on the success of their data sharing between payers and providers. (For more information on HIEs, read our 5-part series.)
The state of Delaware has a success story around the sharing of patient health information, which includes providing access to this data to providers and to payers. The Delaware Health Information Network (DHIN) provides access to patient data for 98% of the population of Delaware. Patients have access to their longitudinal health record through the DHIN-provided patient portal, and almost 100% of lab and radiology results are delivered through DHIN.
This exhaustive coverage of the patient population provides valuable data for both providers and payers alike. DHIN already has technology in place to identify who needs more care, and who needs less. This environment truly fosters a shared-savings approach where all parties have access to the data they need to promote lower costs and higher quality care.
Similarly, California is aiming to achieve the same results.
The California Integrated Data Exchange (Cal INDEX) claims to be the first payer-led HIE, with plans to focus efforts on collecting patient records from both providers and payers. Cal INDEX began in 2014 with approximately 9 million health information records. Much like DHIN, Cal INDEX aims to capture data from the entire state population of California of 38 million.
Cal INDEX has the support of Kaiser and Dignity Health. They plan to give ACOs the clinical quality measures they require to meet payment and quality objectives, just like DHIN. Both providers and payers will have the ability to perform bulk downloads of patient data, as well as access to a data warehouse and analytics tools for population health management.
If it works out, it is essentially a one-stop shop for all payers and providers in California to have access to population health and other shared-savings tools, eliminating the need to go elsewhere to get comprehensive patient data.
Both DHIN and Cal-INDEX have business models in place, which they claim will make them sustainable. HIEs have struggled in building a strategy where they could sustain their long-term existence, but it appears that the shift in payment models and the drive for population health might provide the real need for payers and providers to finally get behind HIEs.