How health insurers profit by hoarding your data
A comprehensive All-Payer Claims Databases would help the health care system become more effective and efficient. The Department of Labor could do something about that, but hasn't.
Last week, I reviewed how health care providers and their computer software vendors refuse to share patients’ electronic health records (EHRs). This issue isn’t just for health care wonks. Allowing patients to control and share their data with other providers would improve care coordination and help eliminate duplication and waste. If the data (stripped of personal information, of course) were housed in a comprehensive health information exchange, it would become a valuable research tool for improving health outcomes.
The main reason providers and their software vendors block the free flow of information is that they are primarily interested in serving their economic self-interest, not the health of their patients or public health. Neither group is interested in facing heightened competition, which would be enabled by the easy transfer of individual EHRs.
The other side of health care transactions are the insurance companies — the payers, who have comprehensive data on how much they paid to whom and for what. The private firms process claims for more than 180 million Americans with employer-provided health care coverage. They also manage the policies of more than 21 million individuals and family members whose plans were purchased on the Obamacare exchanges.
Like providers, these insurers engage in information blocking. Self-interest is at play here, too. They make a lot of money from selling the data.
Insurer data differs in fundamental ways from the data controlled by providers. An EHR contains an individual’s medical history. It typically includes every interaction between a patient and one provider. If the patient receives all their care from an integrated delivery system (a hospital system or large physician practice may have many providers feeding into its EHR), the record may be complete. But that’s rarely the case.
That’s why many states and regions created health information exchanges (HIEs) to facilitate EHR portability. Unfortunately, they are severely underfunded and rely largely on user fees. A recent recent GAO study found only half of hospitals “often” share their EHRs with an HIE.
A payer claim, on the other hand, whether it is paid by public agencies like Medicare and Medicaid or private insurance companies, contains much less information than an EHR. Each claim is a discreet record of what an individual payer paid an individual provider (hospital, doctor, clinic, pharmacy, drug company) for a single episode of care. That ranges from a bundled payment (replacing a knee, for instance) to an individual test, product, or service. In addition to the provider bill and the amount paid, the claim may include demographic data about the patient. It usually has minimal information about the patient’s medical condition that triggered the claim.
Using claims
Though claims databases are limited in scope, they do provide enough information to compare prices, resource use, quality of care, and outcomes. They can also be mined to measure providers on their use of high-value and low-value care, use of high-priced branded drugs instead of generics, and similar issues that make the U.S. the highest priced health care system in the world.