Sunday, November 26, 2017

HIE Future is Bright -- Payers and Providers

The last item on the WISHIN future list is moving to "Shared Responsibility for Managing Care" from "Providers & Payers working Separately" . This seems to be an indication that is mentioned elsewhere, where Payers are being added to the WISHIN network.

It is mentioned
Payer access with WISHIN will become a reality Q1-2018
I wrote a short note about this in the Single Connection Hub article. In that article I emphasized that the technology is enabled for many purposes, including "Payment" purposeOfUse.  So the technology is not going to get in the way. 

Managing Care is a team sport

I think the point of this item is that getting Payers more actively aware of what is happening with the Patients they cover will help improve the Care outcome. This is controversial, and indeed most Privacy theories use just this scenario as a forewarning of bad things. These stories say that when the Insurance company gets too much knowledge of the Patient they will increase the cost of Insurance, and drop support for the kind of medical problem the Patient is suffering from. I am not going to counter this point. I am just going to fully acknowledge that it is possible.

I think though that we could take an optimist view. First, lets use "Privacy by Design" to indicate that the Insurance company access SHOULD be only allowed when the Patient has authorized it. This is not strictly necessary, especially in the USA under HIPAA; as HIPAA fully allows "Treatment, Payment, and normal Operations". But lets assert that a good "Privacy by Design" step would be that the Insurance would have HIE like access only with authorization from the Patient. It might not be mandatory, but it sure would alleviate some worry. I also suspect that a large number of patients would authorize it, enough so that the concept of "Managing Care" by including the Payers is a sound concept.

Second Privacy-By-Design thing I would like to see is Transparency. That was discussed by me many times, it is the function where the Patient is made aware of all accesses to their data regardless of why. In this way the Patient would see when accesses were made by a Payer, and thus feel better the positive outcome. They would also be enabled then to see the negative outcome if it happens. Again, the Transparency helps with proving that the Payer should be trusted, and that the outcome is for the benefit of not just the Payer but also the Patient.

Please don't give Payers unconstrained access to all Patient data. That is a Payer should be constrained to the Patients that they have a Legitimate Relationship with. The alternative is that Payers will troll the HIE for Patients that are rich and healthy, so that they can target marketing.  This Legitimate Relationship is a difficult thing to do, by what authority is this Legitimate Relationship maintained? One solution is that Patient Consent solution I give above. It is however a bit slow. I might not have a solution, but I am worried about the risk.

What benefits?

I think that the Payer has good data on how they are losing money by badly behaving Patients. Things like seeing many doctors for no better diagnosis, such as a hypochondriac might do. Things like drug-seeking through visiting many doctors. I am sure there are many more that I am unaware of, and couldn't quite imagine just how creative Patients are at screwing Payers. All of these are not just ways that the Payer gets screwed, we all are affected. Money lost one way, must be found another way.

Patients, well meaning as they might be, don't always do as they are instructed by their Clinician. I am guilty of this myself. The problem with non-compliance is that it results in sub-optimal recovery. Sub-optimal recover means that a future injury to that area is easier and will result in worse harm. Thus it is in the interest of the Patient to follow the Clinician's instructions, but sometimes it doesn't happen. One of the big ways is that we patients stop our treatment when we feel better, which might be before we actually are better. The well compliant Patient is also in the interest of the Payer, as the payer understands the benefit of optimal recovery, and the future problems of sub-optimal recovery. Thus the Payer really has an incentive to keep the Patient compliant.  It is strange to recognize the fact that the Clinician has no incentive to keep you compliant, except through Meaningful Use disincentive around re-admission. 


I have no question that getting Payers involved can improve care outcome. I am equally suspicious that it could be a benefit only for the Payer. The Privacy-By-Design using the Privacy Principles would be the right thing to do. 

I would love to hear other perspectives on this. Please comment.