Payers must decide how much data to share with ACO providers


You know how when you go on a first date, you're careful not to divulge too much nitty-gritty information about yourself? Instead, most experienced daters prefer to reveal tidbits of their personal lives slowly, so as not to scare their dates off too early with tales of rough childhoods and embarrassing habits. The key to successful dates and early relationships often is a delicate give-and-take balance of sharing some information, but not too much.

That's kind of how payers and providers are acting toward each other as they navigate the accountable care waters. Payers don't always want to spill all their beans, disclosing too much information too quickly, closely guarding their long-held secrets. And providers don't want to move forward with their dates if they remain tight-lipped about important information.

A new report from KLAS Research, "Accountable care payers: Partners in a changing paradigm," about the accountable care strategies of four large payers--Aetna, Cigna, Humana and UnitedHealth--proves how this dating theory of mine can be applied to the healthcare market.

"One of the key findings that we found is this idea of having payers share some of the claims data, which seem to be a pretty big deal from a lot of providers' perspectives to be able to get access to the claims data to have a more complete profile of each of their patients," Mark Allphin (pictured left), the report's lead author, told FierceHealthPayer.

"These relationships are all pretty early and they're starting to change the dynamic of how hospitals and payers work together," he said. "And with early relationships, there are still a lot of details that are still being worked out as far as how to work most effectively with one another."

Allphin explained that, based on his conversations with 14 provider organizations, most payers did actually "come around" to at least share "some basic data with providers." But some payers, like UnitedHealth, remain "hesitant and cautious around sharing claims data." One provider said in the KLAS report it feels like UnitedHealth is "hedging its bets"--it acknowledges that the market is moving toward accountable care, but it isn't willing to share all its claims data.

"The challenge is it feels like they're marching in one direction, but their actions show that they're still operating in a fee-for-service world," Allphin said. The drawback to this approach, he explained, is some providers won't sign an ACO contract with UnitedHealth "because they're not willing to be more open in what data they'll exchange."

Conversely, Aetna "was much more forward thinking as far as sharing and partnership," Allphin said. Aetna has established an all-in approach of committing fully to accountable care. "They are ensuring these agreements are successful ... and they have invested in technology necessary to help their provider partners be successful. And the providers definitely like that model, so they're jumping in full-force to be a partner with payers like Aetna," Allphin said.

But there also are downsides to choosing to disclose so much information right off the bat. "The drawback to that though is it's a pretty serious bet right now to make in such an early world of pay-for-performance," he said. "And quite frankly, we don't know exactly what all these programs are going to cost long-term." Allphin pointed to the myriad aspects of transforming to accountable care models, including hiring care coordinators and putting population health programs in place. Because of all these moving parts, the industry doesn't yet fully understand the whole cost around ACOs.

So how can payers and providers effectively "date" each other in an ACO relationship? Allphin says payers should realize providers want information that will enable them to see a complete view of their patients. Although payers have "phenomenal reports" regarding healthcare costs, providers want more clinical data, including patient profiles and physician performances.  

He added that payers and providers should establish specific goals and expectations upfront, including what each party will commit to, whether that's services as provided by the payers or whether payers are going to provide funding so that providers can focus on population health efforts and have access to care coordinators and claims data.

"There clearly needs to be those set goals and expectations upfront accompanying the contract," he said. "And it needs to be a win-win for both organizations. Both organizations have to feel like it's a good deal for them in order to move forward." - Dina (@HealthPayer)