Jeff Rideout, Chief Medical Officer, TriZetto Group, spoke recently with Healthcare Finance News Senior Editor Chris Anderson about how data will play a part in redesigning the healthcare landscape and the readiness of both payers and providers to collaborate on these changes.
Among all the different stakeholders in the healthcare equation who is the best equipped to bring data to bear to accomplish the goals of improving care while lowering costs?
It depends. This is truly one of the first times where organizations that typically have not worked closely together or in a collaborative way have to come together in that way. The linchpin in all of this is the data, and not just the data itself, but the analysis of (data). What it really comes down to is: what are the goals for the population or the membership or the individual patient you are trying to serve and how do you best line up the resources of what have been typically competing parties to do that? The best example would be an accountable care organization. Typically, delivery-led organizations are in the best position partly because they are going to be managing risk across a broad population.
Are there shortcomings to using data from health plans?
The bias against plan data is that it is claims-based – which was used to pay for things – it is old, and pulling it together usually takes three to six months. Some people describe it as looking through a rear-view mirror, and it is an incomplete view, whereas the image of the delivery system side is that it is all through the front window of the car. The problem is many components of delivery system are just now collecting data and most of that data, even if it is more real-time and more clinical in nature, is not aggregated yet in terms of the population. It is very specific to an individual patient. Somewhere in the milieu, there needs to be some kind of merging of that information. I do think, though, when it comes to accountable care, a good starting point is the plans' data sets in terms of at least looking retrospectively at where the opportunities for improvements might lie.
How can health plans help provide data to help providers with new care models?
One example is analytics. You can ask: "Does a provider have an enterprise data warehouse for the data they have available?" The answer may be yes, the answer may be no. But the ones that do have that pretty quickly understand that they only have the data that is inside their four walls. So how do they get the pharmacy data? How do they get the benefits data? How do they get the contract data, so that I know how to manage these patients against their benefit structure? Asking those questions brings them pretty quickly to the health plan data. Then the question is how do they prioritize these things relative to what are huge investments in EMR systems? Most of the EMR systems were not designed to do actuarial, or analytics or disease registry functions. So that is the moment of truth for delivery systems.