How Payers and Providers can Solve Data Sharing Challenges with FHIR-enabled Data Activation Platform

Sandeep Gupta
Thu 06 Aug 2020
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While value-based care is instilling more efficiency in the U.S. healthcare system, the need to procure and share additional data with other healthcare participants can be overwhelming. Before risk-based payment models had come into existence, under fee-for-service, simple information such as the names of the tests, assessments and procedures were sufficient for processing claims. However, under value-based contracts, healthcare payers also need to know the results to measure the quality of care outcomes. This includes items such as lab results, admission and discharge information, body mass index, vital signs and results of screening procedures and preventative health assessments.

Provider abrasion

The need for detailed data sharing is creating administrative challenges for providers. A study suggests that, on average, a provider communicates with up to 20 payers per week. Further, sometimes payer agents contact a provider for the same purpose multiple times. The unnecessary communication initiated by payer organizations distracts physicians from doing what they are supposed to - care for patients. Clinician burnout is already a huge problem in the U.S., and redundant payer interventions are exacerbating the existing problems.

Competing goals of payers and providers

Another factor that obstructs payer-provider collaboration is their inherently distinct goals. In an arrangement where one party is providing the service and the other is paying for it, the former will try to influence the prices to rise and the latter, to reduce them. Since the healthcare payers are third party insurance providers and not the direct beneficiary of the service, the data exchange process isn’t the most simple arrangement. In addition, providers also hesitate to divulge internal information that is not in their best interest or could have financial implications. 

Competing goals of payer and provider organizations create data roadblocks in the path to achieving overall network efficiency. In the absence of complete clinical information, payers perform analytics and population health statistics based on the claims data alone. As a result, the analytics do not drive significant improvements in processes. On the other hand, providers are also apprehensive to rely on claims analytics, which can ultimately lead to poor outcomes. 

How payers can bridge the data gap with providers

While payers have access to claims data, they lack complete access to clinical data. Even when they have access to all the patient data from the providers in their network, it is very difficult to derive meaningful insights from it right away. A data activation platform can integrate clinical and claims data to provide a holistic view of the network performance to the payers. Payers, in turn, would not have to interrupt providers unnecessarily by asking for clinical data multiple times. Instead, they would be able to improve the provider experience with point of care insights. By assisting providers in delivering care and getting easy access to clinical quality care data, payers can enhance their network performance and improve their member population health.

Leveraging FHIR-enabled Data Activation Platform to improve payer-provider synergy

Apart from integrating, organizing and standardizing the data from disparate sources, Innovaccer’s FHIR-enabled Data Activation Platform provides a novel, in-workflow approach to enable cost-effective care delivery at the point of care without any EHR integration dependencies. The platform simplifies data exchange and comes with an array of features that engage providers and encourage them to work together to achieve shared goals. The platform offers the following benefits:

  • Care delivery excellence in provider networks to close coding and quality gaps and improve performance parameters such as risk revenues, Star ratings, HEDIS measures and more.
  • Empowers physicians and medical assistants at the point of care with actionable, data-driven insights not available in their EHRs to improve care delivery. 
  • Enables frictionless care journeys for patients with improved care coordination between care managers and providers. 
  • Improves the provider network’s experience with point of care prior auth interface to submit requests, respond to follow-ups, and track decisions. Payers can achieve operational efficiency with more streamlined review processes and automated recommendations for their utilization management team.

The road ahead

Value-based care was introduced along with a promise of affordable and equitable healthcare. More importantly, it can only be driven if all healthcare stakeholders are in it together. A growing number of provider-payer collaborations have been gaining traction across the U.S. As a result, the trajectory of risk-based payment contracts is gradually increasing.

Healthcare is in a place where it is ripe for innovation. Payers and providers have a great opportunity to disrupt the space with value-based care being viewed as a critical part of healthcare transformation. With the operations aligned with organization goals, patients are at last being drawn to the center of care, and improving their experience has become a priority.

To learn how to solve payer-provider data sharing challenges with the industry’s most comprehensive Healthcare Data Platform for payers, click here.


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Sandeep Gupta
How Payers and Providers can Solve Data Sharing Challenges with FHIR-enabled Data Activation Platform

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