Without Data, Purchasers are up the Creek

By: Ryan Olmstead, Director, Member Services and Julianne McGarry, Director of Research and Projects - Catalyst for Payment Reform

For employers and other healthcare purchasers who are self-insured, these days you may feel like you are steering a leaky boat through choppy waters without a paddle.?Health care prices, which remained remarkably stable during the first two years of the pandemic, are now poised to spike again.?What’s more, fierce competition for employee talent in an historically tight labor market should give employers pause about shifting health care costs to employees.

Given these challenges, more employers and other health care purchasers will be compelled to implement disruptive strategies that improve health care quality and affordability.?Examples include steering plan participants toward lower-price, higher-quality providers, through network or benefit design strategies, or rewarding providers through mechanisms like payment reform.?The problem is, to execute these strategies, purchasers need access to data; without data, purchasers must steer the leaky boat in stormy seas in the fog, at night, and without a map.

Fortunately, as #ERISA Plan fiduciaries, self-insured purchasers own their claims and clinical data.?Unfortunately, accessing these data – in a timely, accurate and complete way -- has proven a thorny and multi-layered challenge.

Over a year ago, Catalyst for Payment Reform embarked on a project to understand why.?Some key observations emerged.?Health plans may:

• consider the rates they negotiate with providers to be proprietary;?
• consider which providers are in their network also to be proprietary;?
• cite that they cannot provide data about sensitive conditions (e.g., mental health, HIV status) due to legal restrictions; and
• claim that allowing purchasers to share their claims data with other contracted health care vendors (aka business associates) threatens the health plan’s market position.

You noticed we used the word “may”…not all health plans take parallel stances. When CPR asked health plans to report their data sharing policies with respect to their clients and their clients’ business associates (e.g., brokers/consultants, data warehouse companies, point solution vendors), each plan responded differently.

In the course of this research, CPR also learned that health plans are not solely to blame.?Some vendors that contract directly with the purchasers for specific services may also construct barriers to data.?Health care data holds tremendous value -- no one wants to give it out for free.?To air these issues, CPR hosted a virtual summit this past January, titled, “Data is the New Health Care Currency: Are Purchasers Getting Short-Changed?”

To assist purchasers in gaining access to and agency with their health care data, CPR published a toolkit full of resources that purchasers can use to establish their data ownership rights.?The tools are designed to preempt gamesmanship and data hoarding by drawing clear lines of rights and obligations among purchasers, health plans, and associated health care vendors.?Purchasers can assess their health plan or other vendor’s data stewardship policies and leverage CPR’s model contract language to guarantee their ownership and use of and access to their data.?

For each triumphant story of a purchaser gaining unfettered access to data, we hear from three purchasers about data obstruction.?This dynamic must change.?Purchasers should include a core requirement in their Request for Proposals citing they are the owners of their claims and clinical data and decline to contract with health plans and vendors that respond unfavorably.?They should assess their plan and vendor’s current practices and make it a priority to remove gag clauses around ways they can use their data in their next round of contract negotiations.?And they should set parameters around how long it takes to acquire their data, whether for their own use or for their business associates’ use.

Purchasers, to navigate your business past the tsunami of health care data restrictions, you need clear skies and a map.?Get started by attending CPR’s webinar on March 30 to learn how you can get back your data.