Voices from Industry — Health Plans Turn to HIEs While Expanding Population Health Work


It’s a game that works. Like peanut butter and chocolate or Batman and Robin, some things go hand in hand.

Health Plans and Health Information Exchange (HIE) are fast becoming one of the most dynamic duos in the healthcare landscape. Like many great partnerships, there was a bit of history of will or not in the relationship. It took a while for payers and HIEs to find their way to each other. However, there is new recognition today of the rewards of health plans and HIEs working together in the context of value-based care.

Why is it working now? The responsibilities of the health plan to coordinate the overall health of members are increasingly broad and include a broader set of actors, including social service organizations and long-term care as well as behavioral telehealth and telehealth. . This summer’s announcement that US health insurance plans have been renamed simply “AHIP” and adopted a broader mission of “guiding better health” was a sign of the times.

Health plans need quality clinical data to better assess member risks, manage cases, comply with regulations and streamline HEDIS, and also benefit from a secure and neutral third party to help connect with what is. often a somewhat suspicious community of providers.

RELATED: 3 Key Issues To Watch Out For When The Information Blocking Ban Goes In

On the HIE side, health plans bring to the table valuable claims data across all healthcare settings and a desire to use the data to improve patient health – the core mission of all HIEs. Clinical data and claims data together create a more complete view of patient health and care, as many outpatient providers, skilled nursing facilities, and other community providers do not yet share the data through HIEs. Health plans are also an increasingly important source of subscription income for HIEs, helping them to grow and build sustainable networks.

In 2016, a study found that most payers wanted to participate in HIEs by “providing both claims data and accessing clinical data to support payors’ HIE use cases,” but were often discouraged. by HIEs not quite ready to integrate them.

In 2018, the New York eHealth Collaborative advocated for greater payor involvement in health data networks, noting that “payments reform certainly pushes payers to work more closely in managing patient care. through activities such as responsible care organizations (ACOs), patient-centered care homes (PCMH) and more integrated care.

The California Health Care Foundation followed suit with a recommendation (PDF) for greater payor involvement in HIE on the West Coast as well. A 2019 HIE survey showed how the trend has turned with many of the largest HIEs, including payor claims data and 84% of HIEs stating they provide valuable services to payers.

RELATED: Industry Voices: The Future of Healthcare Depends on Improved Data Exchange

Today, many of the largest and most innovative HIEs in the United States include both clinical and claims data in their networks, and they work closely with payers and providers to provide valuable information used to improve health outcomes. Here in California, Blue Shield of California, Health Net, Anthem Blue Cross of California, Aetna, and several large regional health plans all participate in the statewide HIE Manifest MedEx.

The HIE reports (PDF) that payers on its network were able to reduce card hunting for HEDIS by 54% and cut outgoing calls to hospitals by 20%. With the state’s new Medi-Cal initiative, CalAIM, requiring plans to massively increase their capacity for care coordination and population health management, partnerships between payers and HIEs will be increasingly important. throughout California.

A medical manager for a health plan told me that access to “discharge data has allowed us to eliminate a very large number of outbound calls to hospitals to confirm the status of inpatients.” It’s already having such a big impact, and we’re just getting started. “

As the CEO of AHIP noted with their new branding: “Today we are not just changing the way we describe our work, but the way people perceive the role of health insurance providers. in their lives, by making coverage and care more affordable and removing barriers to good health. “

With “removing barriers to good health,” the focus is naturally on getting accurate and useful health data flowing through a diet’s network. For HIEs and Health Plans, this is the start of a very exciting journey together.

Claudia Williams is CEO of Manifest MedEx, California’s leading health data network, and a former senior advisor for health innovation and technology at the White House, where she led health data initiatives and helped to launch President Barack Obama’s Precision Medicine Initiative.


Comments are closed.