TriZetto Chief Medical Officer Jeff Rideout recently spoke with Healthcare Payer News 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.
Q: Among all the different stakeholders in the healthcare equation who is the best equipped to use their power in the market and bring data to bear to accomplish the goals of improving care while lowering costs?
Rideout: It depends. Each organization has something to bring and what I stress to our organization and to customers is that it is not "either or". 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.
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.
Q: Do delivery-led organization have the breadth and depth of data to effectively better manage outcomes and manage the cost of the care, or do the payers have the broadest amount of information to help do this?
Rideout: I think in general, that is directionally correct (that payers have that data), especially if you are going to manage large populations. So organizations that have managed financial risk and actuarial risk will tend to have a broader view of the patients visits, prescriptions, a number of the elements of data that go into managing that risk. That could include a risk bearing health plan or could include a risk-bearing employer group – a self-insured employer. Historically, that is where this type of management should be occurring or has occurred. The problem with health plans' data set is that it is not complete.
Q: So where do providers fit into this picture?
Rideout: The big push now is for clinical data and that includes the data that will be resident as a result of the growing penetration of electronic medical records systems. To come back to the type of delivery system: if you are talking about a multi-specialty group practice that is associated with a hospital system in an integrated delivery system, that type of system will have much richer clinical data and will sometimes have payer data as well as clinical data, because they may own their own health plan.
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 is 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 the delivery system are just now collecting data and most of that data, even if it is more real-time and more clinical in nature it 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.
Q: Do you think the relationship between payers and providers, in general is strong enough for them to be able to work together in this ways?
Rideout: Historically the answer would be no. That is a broad stroke. The relationship that has been defined, even when it has been good, is largely contractual and episodic. In many parts of the country they haven't been good, they've been contentious and acrimonious at times.
That is a tough base to start with, but there are some very good examples from around the country where that is not the case. Perhaps the best instance of that is in integrated delivery systems, or Kaiser-like models, where the health plan and delivery system are already part of the same organization. So there, in theory at least, everyone is pulling in a similar direction. There are plenty of positive models where larger groups and larger hospital systems have found a good working relationship with a plan or multiple plans, but they are either driven by a party like a large employer.
I think the wildcard in all of this is reform. In working around the country, people understand the game has changed dramatically, regardless of what the Supreme Court decides, and that new care models are quite necessary and new attitudes are necessary. I'm not saying that guarantees anything will happen, but if you start to look at it (you will see) how health plans have started to cross the line and now own or are highly collaborative with physicians groups or medical groups. Hospitals are doing the same thing. There is a line between a pure hospital and a physician group that is being blurred. You see physicians and other large groups that are looking to become more like insurance companies.