Preparing to Transform the Provider-Payer Relationship
Expanding Health Care Coverage
April 11, 2012
Primary care providers (PCPs) lack information about what happens to their patients outside of their offices.
Whether a patient goes to an emergency room for a non-emergent condition, is unexpectedly hospitalized, is seeing numerous doctors to get prescriptions for controlled substances, or is going to a high-cost, low-quality specialist, it is often only the health insurance plan—not the PCP—that is privy to the claims records that track these encounters. Yet all these external encounters can result in higher costs and poorer outcomes in the health care system. Institute for Family Health (IFH) recognizes the need for data from a variety of sources to understand where health care dollars are being spent unnecessarily and how duplicative services can be prevented or reduced. IFH examinee how to reduce these inefficiencies by cultivating collaboration among PCPs and payers.
IFH needed comprehensive data from health plans to fully understand its patients’ use of services and where health care dollars are being spent. With NYHealth support, IFH partnered with select health plans to share the extensive cost and utilization data it holds on IFH patients. IFH also integrated and analyzed the external data provided by health plans, in combination with IFH’s internal electronic heath record data, to identify high-cost, high-risk patients, inefficient utilization patterns, and opportunities for quality improvements. Further, IFH implemented interventions to alter costly utilization patterns by targeting patients with chronic conditions since they are sources of high health care utilization and expenditures. Overall, IFH aimed to use these data findings and practice changes to leverage new payment arrangements with the payers to better align financial incentives with high-value care.