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payer Groundhog's Day
February 02, 2021

MedCity News: It’s that time of year – payer Groundhog’s Day

At this time every year payers employ teams of people whose full-time job is calling a doctor’s office, requesting information, and waiting weeks for the data to be mailed in hard copy or being required to physically drive to the provider location to pick up records. How will it get better?

 

Every year at this time, it feels like the movie Groundhog’s Day for many in the payer community. New members, that can run into the tens of thousands, are onboarded. For those in care management, it’s a mad scramble to obtain patient medical histories. The amount of time, energy, and resources spent on largely manual processes continues to be exasperating.

Take Medicare, for example, where more than 840,000 baby boomers aged into the system and enrolled between 2019 and 2020. When these new members are onboarded, care management teams have a very challenging time attempting to close gaps in care. Common questions such as, “when was the last time a member had a mammogram, and what were those results?” are often difficult to answer because of healthcare’s infamous data silos that ensure patient information remains trapped.

Chronic fatigue syndrome


Payers employ teams of people whose full-time job is calling a doctor’s office, requesting information, and waiting weeks for the data to be mailed in hard copy or other physical media such as CDs —or being required to physically drive to the provider location to pick up records. The onus of collecting patient records doesn’t stop with care management.

During reporting periods for HEDIS/STARS measures or risk adjustment evaluations to set rates for plans, administrative teams must chase down records. This Herculean task often requires extra help from outside firms during the January to April crunch time. Many providers find multiple people from multiple departments from the same payer organization requesting the same type of information over and over again in a single year. The result is extraordinary expense and unnecessary fatigue in a records collection process that repeats itself every year.

Interoperability struggles


2020 was supposed to be The Year that would kick health data interoperability into high gear. The Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare and Medicaid (CMS) issued their highly anticipated rules that are intended to improve data interoperability and to prevent information blocking. The rules specify the interoperable data and technology standards for sharing medical records between patients, doctors and payers. The goals are to give patients greater access and control over their medical information to make better healthcare decisions and to spur the type of consumer innovation that is seen in almost every other industry except healthcare.