Industry Voices—Health plans look to HIEs while expanding population health work

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Today, many of the largest and most innovative health information exchanges in the U.S. include both clinical and claims data in their networks, and they work closely with both payers and providers to deliver valuable insights used to improve health outcomes. (GettyImages/ismagilov)

It’s a match that works. Like peanut butter and chocolate or Batman and Robin, some things just belong together.

Health plans and health information exchanges (HIEs) are quickly becoming one of the most dynamic duos in the healthcare landscape. Like many great partnerships, there was a bit of a will-they or won’t-they history to the relationship. It’s taken some time for payers and HIEs to find their way to each other. However, there’s new recognition today of the rewards of health plans and HIEs working together in the context of value-based care.

Why does it work now? Health plan responsibilities to coordinate members’ overall health are ever larger and include a broader set of players, including social service organizations and long-term care as well as and behavioral and telehealth. This summer’s announcement that America’s Health Insurance Plans rebranded to just “AHIP” and embraced a broader mission of “guiding greater health” was a sign of the times.

Health plans need quality clinical data to better evaluate member risk, case manage, comply with regulations and streamline HEDIS—and also benefit from a secure, neutral third party to help connect with what is often a somewhat distrustful provider community.

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On the HIE side, health plans bring to the table valuable claims data across all care settings and an eagerness to use data to improve patient health—the core mission of all HIEs. Clinical and claims data together create a more complete view of patient health and care, since many ambulatory providers, skilled nursing facilities and other community providers are not yet sharing data through HIEs. Health plans are also an increasingly important source of subscription revenue for HIEs, helping them scale and build sustainable networks.

By 2016, a research study found most payers wanted to participate in HIEs by “both providing claims data and accessing clinical data to support payer HIE use cases” but were often discouraged by HIEs not quite prepared to bring them into the fold.

In 2018, the New York eHealth Collaborative made the case (PDF) for stronger payer participation in health data networks, noting “payment reform is certainly driving payers to work more closely in managing patient care through such activities as accountable care organizations (ACO), patient-centered medical homes (PCMH), and more integrated care.”

The California Health Care Foundation followed suit with a recommendation (PDF) for more payer participation in HIE on the West Coast as well. A survey of HIEs in 2019 showed just how far the tides had turned with many of the larger HIEs including payer claims data and 84% of HIEs reporting that they provide valuable services to payers.

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Today, many of the largest and most innovative HIEs in the U.S. include both clinical and claims data in their networks, and they work closely with both payers and providers to deliver valuable insights 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 are all participating in the statewide HIE Manifest MedEx.

The HIE reports (PDF) that payers on its network have been able to reduce chart chase for HEDIS by 54% and to reduce outbound calls to hospitals by 20%. With the state’s new Medi-Cal initiative CalAIM requiring plans to massively ramp up their care coordination and population health management capabilities, partnerships between payers and HIEs will be increasingly important across California.

One medical manager at a health plan told me that having access to “discharge data has enabled us to eliminate a really significant number of outbound calls to hospitals to confirm inpatient status. It’s already making such a big impact, and we’re just getting started.”

As AHIP’s CEO reported with their rebrand, “Today, we’re not just changing how we describe our work, but how people think about the role of health insurance providers in their lives, from making coverage and care more affordable to breaking down barriers to good health.”

With “breaking down barriers to good health” naturally comes a focus on getting accurate, useful health data moving across a plan’s network. For HIEs and health plans, it’s the start of a very exciting path forward together.

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