A Payer Perspective on the Value of HIE

Two members of the HIMSS HIE Toolkit Task Force recently interviewed Marty Hauser, a CEO of a large, multi-hospital organization in the Midwest. Their discussion focused on impact value and operational benefits of health information exchange organizations (HIOs) to the healthcare insurance industry.

Health Information Exchange (HIE) is generally recognized as having two definitions, one as a verb and the second as a noun.

  • The verb “HIE” is the sharing action between two or more non-affiliated organizations with an executed business/legal arrangement that have deployed commonly agreed-upon technology with applied standards for the purpose of electronically exchanging health-related data between the organizations. Federal and state policies have been created to encourage the verb health information exchange, an approach supported under the State Cooperative Agreement Grants awarded by the Office of the National Coordinator for Health Information Technology, or ONC.

 

  • ”HIE” in the noun form is a catch-all phrase for the health information exchange organizations (HIOs) providing data exchange under the legal arrangements described above. This includes private exchanges, state HIEs, regional health information organizations (RHIOs), quality information organizations (QIOs) and some accountable care organizations (ACOs). (See The Business Case for Interoperability and Health Information Exchange for additional information about these organizations.)

Investing in an HIO: During our discussion, Mr. Hauser acknowledged the potential benefits of HIOs.  However, he also emphasized the highly speculative nature, especially for payors, of the distance between today’s investment and future value.

Although HIOs provide a good mechanism to move data between multiple points of care, the initial costs of activation may outweigh any immediate economic value.  In addition, patient care value can be substantial, if it supplants the existing, tried-and-proven means for health data exchange.  However, it is important to recognize that the value proposition is between the care delivery organizations sharing relevant patient data with each other, and not specifically with the health plan or payor.

Understanding Health Plan HIOs:  With health plans, HIOs are prevalent, supporting strong networks of data movement between healthcare organizations and their trading partners (borrowing lexicon used by HHS for the ICD-10 initiative) that transport the claim information to the healthcare organization for processing.  For example, in 2012 the Beacon Community of the Inland Northwest (BCIN) indicated that over a nine month period 2,800 patients with Type 2 diabetes enrolled in BCIN programs (see examples in the HIMSS Health IT Value Suite). This instance demonstrates value from improved disease surveillance and longitudinal patient analysis which could ultimately leads to savings from an efficiency and operational standpoint.

Thus, in many ways, the incentive for broadening the use of HIOs will stem from the trading partners, since it is in their direct financial interests to see claims submitted and processed as expeditiously as possible. Possibly, the most useful role of an HIO for a payor will be in claims queries, where a payor will be able to access or request additional information pertaining to a claim, potentially shortening elapsed time to claim adjudication.

Benefiting from the data exchange:  Healthcare organizations can benefit from an HIE-anchored approach by leveraging a mechanism that moves claims information from the trading partner back to them via HIE in a single, commonly accessed data ‘highway.’  In such a scenario, healthcare organizations would be able to:

  • reduce the number of individual trading partner interfaces and optimally,
  • consolidate into a single connection.

Accelerating better patient care with HIOs:  The many HIOs in the initial phases across the USA primarily operate at a local or regional level.  For HIOs to be useful for large payors, especially those operating across state lines, a common HIO will need to emerge.  Connecting to multiple HIOs simply moves the point of connectivity, while not necessarily reducing any cost or processing burden for health plan payors. In fact, such an approach could well result in a short-term cost increase with no discernable lasting drop.

Thus, the value of HIOs for healthcare payors has yet to be established through a compelling financial incentive.  While the concept of an HIO used by payors is alluring, the financial benefit is not yet clear.  However, as the HIE environment matures for accelerating better patient care, it will likely evolve the benefit for trading partners and payors alike.

 

What are your thoughts on the benefits of the HIO for payors and healthcare organizations?  Share them here on the HIMSS Blog.

Interview Conducted by:

Carl Jaekel, MSTM, CPHIMS, CHSP                          Zeeba Mercer

MedMutual                                                                       Excelarise, LLC

Cincinnati, Ohio                                                              Macedonia, Ohio

Carl.Jaekel@medmutual.com                                    Zeeba.mercer@excelarise.com

 

About Mari Greenberger, MPPA

Director of Informatics at HIMSS North America
This entry was posted in Clinical and Business Intelligence, HIEs, Interoperability & Standards, Payers and tagged , , , , , , , . Bookmark the permalink.

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