Healthcare stakeholders weigh value of claims and clinical data | Health Data Management

Prior to the introduction of the electronic health record CMS (Medicare) and other health plan administrators relied upon claims data.  Now the mandate of meaningful use has made clinical data available via the electronic health record.

Physicians disparage the EHR because of it's disruption of the clinical encounter and inefficiency in data entry.  Few would deny the enormous data collection which has taken place.  

As a result two enormous data sources are available.

In healthcare, claims data is often described as a river that is a mile wide but only an inch deep, while clinical data—the analogy goes—is a mile deep and an inch wide. Yet, with the widespread adoption of electronic health record systems by providers, claims data often gets short shrift relative to EHRs.

However, understanding the distinctive benefits of claims and clinical data is critical if providers are to properly exploit their respective values.
Isaac Kohane, MD, chair of the Department of Biomedical Informatics at Harvard Medical School, knows better than anybody the value of different kinds of data and their respective limitations. As Kohane points out, EHR data is definitely more detailed than claims data. However, he believes there are circumstances when the latter is more useful than clinical data.

For instance, Kohane contends that research shows that claims data is more predictive than genomic tests for parents who have had a single autistic child looking to understand the probability of a second child having a diagnosis of autism.

While emphasizing that he leverages EHR data for a lot of analyses, Kohane points to an ongoing “sponsored research agreement” with health insurer Aetna that provides Harvard researchers with access to tens of millions of anonymous claims records from across the United States used to examine relationships among diseases, their consequences, and their heritability.

As it turns out, a detailed family history is often the most informative data for understanding inherited disease risk. However, very few EHRs provide the capability to easily enter a family history and link it to the broader genealogy. “What we’re trying to do is make medicine a much more data-driven discipline,” adds Kohane.

Still, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, characterizes the difference between the two data types—claims and clinical—as breadth versus depth. He observes that EHRs give providers really deep data about patients for specific medical events and the overall context.

“If you only have claims data you would only be able to infer, for example, that a patient is diabetic or has pneumonia because there is nothing in the claim that tells you so,” says Tripathi. “All you know is that Blue Cross paid the provider to test for those conditions. You don’t actually have the test results. But, with clinical data, you find out what happened. In the EHR, you will have the actual lab results.” At the same time, Tripathi believes claims data is generally “cleaner” than clinical data given that the former is simpler in design and that payers actively monitor medical billing in a way that EHR data is not.

“The problem with clinical data is there are lots of individuals who are documenting in their own unique ways that is not enforced on a day to day basis,” he adds. “One of the things about claims and financial data is that when it is submitted with the wrong codes it will get rejected right away because everyone one of those is sent through a central payer. That means providers will not get paid, so they care about getting the coding right.”

However, DeSalvo charges that both claims and clinical data are “super” dirty. “I’m not sure what’s worse,” she says.

The changing impact of value based care vs. fee for service reimbursement.

Nonetheless, as the industry transitions from fee-for-service to value-based payment linked to quality, performance and reducing costs, DeSalvo contends that the more access providers have to clinical data about outcomes is going to be critical to ensure interventions are actually improving healthcare and not just decreasing utilization.

“The Holy Grail has always been the clinical data for the scientific, public health communities, and those interested in analytics, because it gives you some sense about outcomes more than process and help provides a window into complexity and control factors—particularly high-cost, high-need patients with chronic diseases—as opposed to just knowing what chronic diseases they have,” says DeSalvo.

When it comes to value-based purchasing and risk contracts, John Halamka, MD, chief information officer at Boston’s Beth Israel Deaconess Medical Center, contends that a repository of both clinical and financial data is needed by providers to succeed.

“That’s the only way to compare outcomes (clinical), quality (clinical), and total medical expense (financial) across providers,” says Halamka.

According to Kheterpal, one of the advantages of claims data is that it follows patients regardless of where they receive care.

Kheterpal agrees that major claims data holders—like health systems with their clinical data—have business strategies built around restricting access to information. However, he mentions that not-for-profit claims data holders such as the Blue Cross Blue Shield Foundation and Blue Cross Blue Shield of Michigan “do not view that data as a revenue stream and a strategic differentiator” but as “an enabler of research and clinical quality improvement.”

Lack of payer, provider info sharing complicates shift to value-based care

Although collaboration between payers and providers will be critical if they are to succeed in transitioning to value-based payment models, they continue to struggle with information exchange in the current fee-for-service environment.

That’s the finding of a new survey of 40 health plans and more than 400 practice- and facility-based providers, which found significant communication gaps between the stakeholder groups.  In the survey, conducted by health IT vendor Availity, the vast majority of payers and providers (84 percent of practice-based providers, 76 percent of facility-based providers and 68 percent of payers) view administrative waste—finding the right point of contact, long wait times and frequent policy changes—as a significant cause of poor communication.

In fact, the survey results show that slightly less than half of practice-based providers report difficulty communicating with and interacting with payers, compared with almost a third of facility-based providers. Among the top issues identified by providers as leading to dissatisfaction with payers are: redundant information requests, denied claims and uncompensated care, as well as inconsistent rules among health plans.

“The payers and the providers have created administrative waste, and that’s one of the significant causes of poor communication and is adding to the cost of healthcare,” says James Leatherwood, Availity’s product manager for portals. “That comes in a variety of ways, including multiple requests for the same information, which just add cost unnecessarily.”  

Currently, when providers have questions about prior authorizations, denials or payments, they call the payers. In the survey, more than 90 percent of providers and 68 percent of health plans indicated that they consider the phone to be their primary means of communication.

“Frankly, I was very surprised that 90 percent of the providers think that the phone is the best way—or, at least, the most commonly used way—to reach out to the plans,” adds Leatherwood, given the long wait times associated with this mode of communication and other inefficiencies.

While online portals are a potential solution for better managing communications, the providers and payers surveyed view the technology differently: 60 percent of payers would prefer the use of online portals as the primary means of communication, but only about 40 percent of providers were as enthusiastic.

“The plans would much prefer the providers to use the electronic tools,” observes Leatherwood. “The providers would prefer to be able to get the answer that they need, regardless of where that comes from. They don’t see the portal as the most effective way to do it based on our research.”

Nonetheless, multi-payer portals are seen by providers as simplifying the workflow by reducing the number of sites that have to be checked for patient eligibility, benefits, claims status and other insurance-related data. In the survey, a multi-plan portal was preferred by 42 percent of facilities-based providers and 35 percent of practice-based providers.

Ultimately, Leatherwood believes that having the ability to share information in advance of treatment—rather than just after care is delivered—is where the industry needs to improve if value-based payment models are to be successful.

“When the plans and providers work together, healthcare gets better,” he concludes, resulting in “better outcomes for patients, creating a healthier America, as well as saving money and reducing the costs of care.”

Ultimately the streamlining and fusion of both sets of data will result in better statistics. The statisticians have their hands full, and depend upon provider input.

Healthcare stakeholders weigh value of claims and clinical data | Health Data Management