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"ACOs Complain of Problems With Payer Data, but Some Say They Expect Too Much "


Reprinted from ACO BUSINESS NEWS

As more provider organizations seek out accountable care partnerships with insurers, those nascent ACOs say they are bumping up against a sometimes unexpected but very real problem: The data the payers are able to provide them with isn’t always high enough quality to be usable.

This has led to struggles as the ACOs attempt to reconcile their internal data with the data provided by insurers, and to difficulties getting data on services to attributed patients from non-ACO providers, industry insiders say. Provider-run ACOs are finding they need to double-check claims data from insurers with an eagle eye, and also must develop new procedures — such as universal consent forms for data-sharing — to make certain they obtain the information they need.

But one consultant who works with both providers and insurers counters that the problems stem partly from the fact that many in the ACO world are expecting too much from the available data. “Everyone’s expecting perfection,” Erik Johnson, senior vice president at Avalere Health LLC, tells ABN. “Everyone assumes that all the hard work [on data collection and interoperability] has been done and the foundation’s been laid. Therefore, nobody’s doing it.”

And Cigna Corp., which intends to operate 100 ACO partnerships with providers by next year, says it is working to add the ability for ACO partners to correct errors in its data.

Crystal Run Healthcare, a Medicare Shared Savings Program (MSSP) ACO that’s actively seeking commercial ACO contracts (ABN 4/13, p. 7), has struggled with the problems inherent in inaccurate, incomplete data provided by its potential insurer partners, says Scott Hines, M.D., co-chief clinical transformation officer for the 300-physician practice.

“We’re dragging payers kicking and screaming to get them into shared savings,” Hines tells ABN. “We have one or two payers where we’re very close to getting something done, and we’re at the point where they’ve provided us with data.”

When that data arrives, Hines says, it’s often remarkably inaccurate: The insurer doesn’t even have the right physicians listed, or includes physicians who were associated with Crystal Run years ago but who since have left the group. In addition, “most of the plans here aren’t managed care plans, so how do we get patients attributed?” he asks. “Our idea of how to do this many times differs from theirs.”

When it comes to data on quality measures such as preventive services, “our numbers are often very different from the numbers the insurance company is providing,” Hines says. “It’s not easy to meld these two together. Many times we’re correcting their data.”

Insurers in Crystal Run’s area of Middletown, N.Y., are not accustomed to providers who need accurate, complete claims data, and they don’t have the staff to pull it together, Hines says. “I feel that, with some payers, we actually have better data than they have and more health informatics expertise than they do.”

Incorrect and missing data hasn’t been as much of an issue for the payers with which Crystal Run likely will contract first in ACO-type arrangements, Hines says. Insurers that are further behind on this issue also seem to be further behind on other issues required for shared savings-type arrangements. Still, bad insurer data is not necessarily a deal-killer, he says.

However, it’s critically important for insurers to be willing to share all the claims data for attributed patients, not just claims data involving services provided by Crystal Run, Hines contends. “Some insurers are reluctant to give up that data — they feel it’s a valuable asset they have. But to be successful in accountable care, you need that claims data. Physicians should have as much right to claims level data as insurers.”

It doesn’t make any sense, Hines says, for an insurer to decline to help an ACO identify “the sickest of the sick” when that ACO, with embedded care managers in its primary care practices, is in the best position to manage those sick patients’ care.

Allina, Payers Work to Reform Process

Minneapolis-based Allina Health has run into similar problems getting necessary claims-level data from commercial insurers, says Patrick Flesher, Allina Health’s director of payer contracting and Pioneer ACO.

However, Allina — which runs a Pioneer ACO with about 13,000 attributed members and also has four or five risk-based contracts (ABN 4/13, p. 11) — is fortunate to operate in an area where risk-based contracts are much more common, and insurers have been “pretty supportive of reforming the process” of exchanging data, Flesher says.

One of the issues, he says, is getting all the data from a particular insurer on patients who are cared for by Allina providers. “They might give us the Allina data but not data on those patients from outside providers.” However, Allina needs that data on outside patient services in order to properly manage ACO patients, he notes. “We need to have the full picture of what’s going on with the patient,” he says.

In the Medicare Pioneer program, patients automatically opt-in to share their data with the ACO, although they must be given the opportunity to decline this data-sharing. To deal with the problem on the commercial side, Allina developed a consent form for all of its patients to sign that gives Allina the right to claims data for services provided outside the ACO.

This wasn’t an easy task, since some of the health plans Allina works with wanted their own particular wording on the consent form, while Allina needed to create one form that would work for everyone in order to keep the process simple enough to manage effectively, Flesher says.

Even with the consent form, Allina isn’t getting everything it could wish for, Flesher says. For example, it’s difficult to tell if the claims data received is accurate, even once it’s compared to internal ACO data. “You do have to take a leap of faith on it, although if something looked really off you probably would notice. The data [Allina is getting] is not perfect, but it’s getting better,” he says.

Complaints about inaccurate and missing data are “accurate but almost irrelevant,” since many in the ACO world are expecting too much from the available data, Avalere’s Johnson tells ABN.

“Part of it is some naivete about how comprehensive a non-claims database is,” says Johnson. “All we’ve really got is claims data. Everyone has an incentive to make sure the claims are accurate. Claims can tell you a lot — they can get you well down the road as to which providers are doing the right things and ordering the right tests.”

Claims data is complete and generally accurate because it’s necessary to pay providers, he says. “Maybe it isn’t sufficient, but it’s the best we’ve got. It’s the only source of data that’s 100% complete, and the data standards are pretty well fixed. Everything on the claims side is pretty interoperable.”

Johnson says ACOs in partnership with private insurers need to accept that and to start with the data that’s available — generally only claims data — and build on it to add clinical data that’s being collected by both providers and insurers. “It’s an evolutionary process,” he says.

Dick Salmon, M.D., Cigna’s national medical officer for performance measurement and improvement, agrees that there are limits to the data currently available, even as he maintains that Cigna is giving its ACO partners as much as it can to help them succeed in care management and cost containment.

Cigna now is partnering with a total of 56 provider groups on ACO projects, and has more than 600,000 members in ACO plans, Salmon says. The insurer also has an advisory panel made up of providers from its ACOs that “tells us what they really need” in terms of data.

For example, the data Cigna gives to its ACO partners includes information on which patients are in the hospital, their diagnoses, and when they’re going home, he says.

However, “for many patients we actually don’t have discharge data real-time — we get informed a day or two later,” he says, adding that Cigna’s ACO partners want and need that information in real time.

In addition, Salmon acknowledges that some of the data provided to the ACOs contains mistakes — for example, it might show that a particular diabetic patient didn’t receive a necessary test when in fact that patient did obtain the test. “Would we prefer that these things didn’t exist?” he asks rhetorically. “Of course.”

In fact, in 2014 Cigna will add the ability to take data corrections back from its ACO partners in an effort to fix these mistakes, Salmon says. Still, he acknowledges that there’s plenty more progress to be made in supplying ACO partners with accurate, actionable data.

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