January 25, 2019
Member Q&A with Kyle Anthony, Director of Human Capital Practice at Oswald Companies
Historically, brokers have focused on improved access and utilization of claims data. However, it is no secret that multiple challenges exist with the manner in which claims data are provided given the fragmented nature of the healthcare system. Clinical data, on the other hand, is a more recent focus for leaders in the employee benefits industry. Gaining access to this data may be the greatest opportunity to affect cost. From value-based contracting to targeted gene-based therapies, the clinical information and availability of patient medical history to individuals—and by extension, the providers and organizations managing their care—has the potential to unlock huge value.
On the policy front, in rare alignment with the Obama administration, the Trump administration continues to carry the torch on promoting improved clinical interoperability, an exercise that promotes changing the way personal health information flows (or more accurately doesn’t!) throughout the healthcare system.
We caught up with Kyle Anthony, Director, Human Capital Practice at Oswald Companies to get his take.
What do you think are the biggest obstacles to obtaining access to health information?
A key obstacle is the ongoing debate over who truly “owns” the data.
When I was a kid, health records were recorded on paper, owned by the physician. Payment for claims was typically in cash. (Thanks Mom & Dad!)
Today, electronic medical records are managed by healthcare systems who secure more than 80% of their reimbursements from health plans. With today’s complex system, identifying ownership is far more challenging.
In the December Leader’s Edge, Scott Sinder captured the fundamental issue – pointing out that “…whoever has data in their possession can use it for any purpose whatsoever unless there is a regulatory or contractual prohibition on doing so.” Unfortunately, the access that we seek as advisors won’t happen circuitously with these murky rules around ownership.
There’s a lot of talk around leveraging HIPAA’s “right to access” as a potential pathway. In my opinion, the ability for an enrollee to transfer their “right to access” to their employer isn’t a practical solution. Even if an employer successfully secured the necessary authorizations, I don’t see health plans feeling compelled to release what they consider proprietary and confidential information without competitive pressure (or perhaps a threat of litigation).
Only when the industry directly addresses access, through fundamentally modifying contractual agreements among the stakeholders, can we ensure consistent, secure and meaningful access.
If the commercial market could take advantage of government advancements and HIPAA’s right to data provisions (ultimately enabling interoperability at the enrollee level), what would a use case scenario look like in which these data create unique value?
Take diabetes, the leading cause of death in the United States and one of the most prevalent expense drivers for employer sponsored healthcare. With the right advancements to enable more meaningful use of data, we could achieve so much on behalf of our clients and their participants.
The proof is already here today. Organizations such as the Indiana Health Information Exchange (IHIE) have been connecting providers, patients and health plans to improve the patient experience and health of populations while reducing the cost of care.
One of Oswald’s partners, Anthem Blue Cross Blue Shield, recently participated in a pilot study with IHIE to expand their clinical information. Anthem’s claim information could historically report whether an insured actually had a check of their blood sugar and cholesterol levels, but connecting to IHIE clinical information expanded their perspective. Through the pilot, Anthem increased their target population’s clinical data by 9X and was actually able to determine if an insured’s diabetes was under control.
While just one pilot, the data provides a real-world opportunity to impact the insured’s quality of life, the value of healthcare and ultimately lower the cost/quality ratio.
How does this conversation intersect with the push toward value-based care?
The IHIE/Anthem pilot demonstrates the impact of identifying, monitoring and engaging different groups of patients. Free flowing data allows collaboration between healthcare providers, health plans and employers, facilitating the transition toward value based care.
The Anthem pilot proves that better identification of patients, who required targeted intervention, could successfully prevent high-cost life altering complications when the health plan operates in partnership with providers.
It’s all about ensuring patients can be treated at the right time, in the right way at the right place. The incredible potential beyond Anthem’s pilot, as interconnected data enables health plans and providers to leverage predictive capabilities before people become sick, is where I’m excited to see the innovators begin their development.
How do you think new ventures like Amazon Berkshire Hathaway JP Morgan Chase will affect this conversation?
The innovators, like these new ventures, are uniquely positioned to convert unstructured text, such as medical notes, prescriptions, or pathology reports into actionable health data. Whether it’s Amazon, Berkshire Hathaway and Chase, Alphabet or Apple, new ventures are certain to enter the market and eventually disrupt the status quo.
It’s widely known that Optum, Apple and Alphabet are all working to scrape information from medical records to better predict risk.
Back in November, Amazon confirmed they’re also working on a project, which leverages machine learning to more accurately diagnose disease through the mining of patient records. Rather than displace traditional medical record companies like Cerner, Amazon reportedly sees greater potential in focused efforts around clinical trial support and population health. I tend to agree.
Personally, I’m eager for the day I can simply “Ask Alexa” if I have a cold, the flu or a sinus infection, and know her response will be informed based on my medical history. While maybe next door at my neighbor’s house, Alexa reminds a chronic claimant to test and submit their blood pressure for monitoring by their primary care physician, from the comfort of their own home.
The potential of what we can do together to improve the cost/quality ratio is unlimited. It’s unfortunate that without clear pathways toward the sharing of data, we’re stuck looking for the “on-button”. As guardians of employer-sponsored healthcare, and integral advisors to the entire system, we must continue to insist on establishment of a secure and connected framework that enables transparency of claim, quality and clinical data.