Payer Update, November 2019

Patient Data: Who Owns It, How Do You Use It, and Why Should You Care?
By George Oestreich

As is routine for any patient visit, the provider obtains patient-specific information, both demographic and clinical, and preferably saves the patient information in an electronic health record (EHR) system. This information is used to develop plans of care, continue treatment and track the health trends of the patient. The patient owns this collection of protected health information (PHI) while the record itself is owned by the provider or treatment site (the Center). The Center will typically ask the patient to sign a waiver to legally enable sharing the PHI with specified family members and to authorize its use for billing the provider’s products and services. Some providers are reluctant to share patient data, even with another provider. This may stem from a belief that if the data is shared, the patient may take it to another provider. Alternatively, the treating provider may believe that the PHI data belongs to them, not just the record.

It is time to revisit data sharing policies and issues. The review should include the data that is collected, stored, and shared with other parties. The healthcare industry is entering a brave new world that uses alternative payment models (APM). Two APMs being increasingly utilized are value-based reimbursement (VBR) and value-based purchasing (VBP):

Value-based reimbursement (VBR) is the payment model for medical services that is gradually replacing the traditional fee-for-service model for payers and healthcare organizations. The goal is to cut rising healthcare costs by switching from a model based on quantity of units delivered to value-based reimbursement, which is based on quality. The quality can be subjective or in some cases objective depending on the disease state treated (i.e., pay based on the number of diabetics in a physician panel that are at their A1C goal). This attempts to link quality of case to the best performing providers. This also assumed that the level of effort is the same for all chronic disease and if not how you rank the effort and the relative value.

Value-Based Reimbursement (VBP): Linking payments to improved performance or efficacy of drug products. This form of payment holds manufacturers accountable for the cost of their products in the context of the efficacy the products produce in treating a chronic disease in a patient panel. The most prominent example was promoted by the SmartD program and produced the “Netflix” like pricing or aggregate pricing from Hep C drugs to the populations of patients with the disease. Example: the drug cures HepC in 85% of patients, the challenge is making sure the patients take the medication and that they are not reinfected. Also often a problem is defining what “cure” is in the contract.

These program management tools are ever more frequently being utilized by both state and federal payers as well as by the private sector payers. There are 40 states with Medicaid managed care and 28 of them now require VBR. The number of payers using VBP is also growing quickly. All of these program management tools rely upon an interface with the patient’s PHI.

It is imperative to accurately and consistently collect, record, store and share PHI with other healthcare delivery participants for the mutual benefit of all parties. Accurate data is keenly important to properly reflect the clinical information and thus receive adequate reimbursement for provided products and services. The future will rapidly continue to emphasize the use of clinical data interfaces.

It should also be emphasized that this data is still subject to the Health Insurance Portability and Accountability Act (HIPAA) legal requirements. Serious penalties will accrue if violations are found by federal and state regulatory reviews. The vast majority of data that may be used in VBR/VBP is deidentified, but the new HIPAA guidelines may be more stringent than before when considering small populations with special health needs.

Healthcare providers will begin seeing their reimbursement based on patient outcomes established from collected data. The data may be used to produce comparisons between peer providers or simply compare trends for chronic diseases. The efficacy of products is also subject to pricing established from data trending. With the new highly expensive products this form of contracting will only increase.

With the effective use of data and an understanding of the process of VBR, the Center will be prepared for the future APM. Appropriately following your patient’s data will also support the integrated comprehensive care model, increase their positive outcomes and aid in the benefits of monitored transitional care. The data supporting the quality of the Center’s care leading to fewer bleeds, tight assay management, and less tertiary care with overall better outcomes puts the Center in a position to support higher reimbursement.

It’s time to start loving your data, whether it is subjective or objective, clinical notes, or units of a product dispensed by the pharmacy. It is also a good time to scrutinize the data you do collect so you can get the most value for your effort and have it tell a positive story about the Center. Collect, record, and verify the accuracy of your data to increase its benefits and prepare the Center for the future shift around data in healthcare. Remember, if it’s not written down, it’s not really “done”. Without the recorded data you have no story to tell.

Also in this Issue…

Notes from Joe
· Back to the Future

Washington Update

Legal Update
· Supporting Patients while Steering Clear of Fraud

Notes from the Community
· Update from the Hemophilia Alliance Foundation

Alliance Update
· Alliance Operations Update
· 2020 Meeting Schedule

Team Alliance Contact Information

We work for you! Please don’t hesitate to contact any of us with any questions or concerns:

Name Email Phone
Joe Pugliese 215-439-7173
Sean Singh 727-388-7326
Jeff Blake 317-657-5913
Jeff Amond 608-206-3132
Johanna Gray, MPA 703-304-8111
Elizabeth Karan 612-202-3240
Kimberly Wolverton Lackman 813-400-6710
Roland P. Lamy, Jr. 603-491-0853
Dr. George L. Oestrich, Pharm.D., MPA 573-230-7075
Ellen Riker 202-257-6670
Mark Plencner 701-318-2910
Michael B. Glomb 202-466-8960
Theresa Parker 727-688-2568
Karen Bowe 717-571-0266
Joel Bellucci 727-504-0491