Good news or bad? Insurance companies "own" clinical data...

The big news of the week – Aetna’s acquisition of Medicity – understandably has created a buzz throughout the industry.

In theory, the notion of genuine health information exchange (HIE) between providers and payers makes sense. Unfortunately, the “all for one and one for all” rallying cry holds little credence among providers – particularly if payers hold the keys to the castle.

Providers view sharing patient information with skepticism, even when the exchange occurs with a “friendly” entity, like a local hospital. They worry about the security of the information and that the data they offer may be put to nefarious use – to plot referral patterns, for example, or to extrapolate other business intelligence. 

Consider the level of misgiving, then, that accompanies the idea of sharing information with a traditional adversary.

Unfortunate though it may be, providers become wary when payers declare an altruistic dedication to improved clinical care. Cynicism abounds when providers feel payers go to great lengths to minimize reimbursement. 

In other words, the Aetna-Medicity deal may do little to resolve the impasse that exists between payers and providers, despite the homage paid to the importance of clinically integrated HIE – unless, of course, the company commits to genuine two-way information exchange, and uses the information to improve its own processes and workflow.

There’s no question about the potential that claims data holds to enhance clinical care. Providers along the entire continuum of care would have comprehensive visibility into the diagnoses, therapies, treatments and medications their patients receive. Clinical decision-making could be improved and waste reduced.

Conversely, payers could improve their own efficiency by taking advantage of the EMR data that would suddenly be at their fingertips. Imagine how much time could be saved in the pre-authorization process if payers relied upon information already at their disposable, rather than continuing to require physicians to fill out paperwork, submit faxes and emails, and schedule conversations with reviewers?

Here’s another example: My own practice recently was penalized when a payer declared we were not meeting standards for prescribing generic medications – when, in fact, we exceeded the payer’s parameters. We use electronic prescribing through our EMR and our patients often pay cash when picking up their medications. Claims data alone, therefore, did not provide a full picture of our prescribing habits – but information contained in our EMR would have supported our practice.

Bottom line: the idea of clinically integrated health information exchange has potential. But few on the provider side of the equation believe the promise will be borne out in practice if left in the hands of payers. If their deal is to succeed, Aetna and Medicity needs to commit to genuine bidirectional data sharing and begin to regard the provider community as allies in the effort to improve quality and reduce the cost of healthcare. 

In short, dialog must trump dollars. 

 

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