• Adam Tabriz, MD

Double Standards Of Claims Data In Healthcare

Claims Data Is A Valuable Tool In Doubling Down On Quality Medical Care But, Seems Too Valuable For Insurance Industry To Share

Illumination publication initially publicized this article on Medium!


Photo by Campaign Creators on Unsplash

In a world of ours where human lives are becoming digitalized by the day, data is also turning out to be an invaluable asset. Like the gold miners' old days who had their hands on the precious metal and the backing for the monetary system in the world, so is data in the modern era.

The beholders of the information, I mean, any form of data from any industry or person, hold a piece of an asset. And one can trade that asset as long as they have access to the cloud network.

One form of such information that is particularly important to healthcare and thus is extremely valuable is the so-called "Claims Data."

Claims Data is the set of extensive "administrative data" in the healthcare domain. The databases or information silos containing the Claims Data comprise a detailed collection of millions of doctors' appointments, bills, insurance information, and other communication between doctors and patients.

Claims Data Is Not The Electronic Health Record Content

Let us not confuse Claims Data from patients' health information with data collected from Electronic Health Records (EHR) Systems.

Claims Data is more about the indirect way of studying public health trends.

Researchers have shown significant interest in accessing Claims Data in the recent decade. Because they feel analyzing the information will help gain insight into various aspects of medical care delivery that may not be available in the patient's records. That is, items like sensitive information about groups or patients are prone to fall through the cracks regarding self-reporting. For example, in an early study, only 2% of syphilis sufferers reported the condition.

Claims databases also assist researchers in finding sizable groups of patients with rare conditions who might be challenging to locate by other standards. These are diseases like quadriplegia or aplastic anemia. Claims data may also be a valuable tool for verifying the cost of particular diagnoses.

Although there are also particular critiques on the useability of Claims Data, one thing worth looking attention to is that insurance companies are ironically reluctant to share that information with the research communities and even physicians and patients.

Irrespective of how valuable the Claims Data it comes to me as an utterly contradictory standard.

While insurance companies gorge on patient and physician information to improve the healthcare delivery system without paying any penny, they are unwilling to share the data they have siloed under precisely the exact cause!

The further irony is that there are no regulatory provisions, as I am personally aware of, that force insurance companies to share Claims Data with 3rd party agencies.

Nevertheless, the question is why should Insrance companies volunteer to share their Claims Data?!After all, Less the other stakeholders in the healthcare community know about certain 3rd party payers activities less they have to answer to questions that may arise, right?!

Of course, payers are no spring chicken, as more complexity in the payment process means more burden on physicians in submitting bills. Thus fewer questions are asked. Furthermore, This issue of attribution is the second major obstacle. As medical practices steer around alternative payment models (APM), their demand for global claims data becomes more pressing.

Insurance companies use a so-called attribution methodology to decide which beneficiaries are in quality, cost performance factors, and payment adjustments under the Value Modifier. Most of the time, APMs base their attributions on only primary care utilization or, for a specialist participating in bundled payments, on "typical costs for clinically-defined bouts of care." They also establish it on the specialty provider performing that bundle's index service.

Interestingly, the payers have found a way to navigate it by trying to avoid attributing the same patient to two different physicians. Mere because they seem to have policies that state:

For payers to share Claims Data on a particular physician, a minimum number of their members must be attributed to that provider for them to be amenable to sharing.

Insurance companies are constantly mining for data solely proprietary assets of patients and physicians. Insurance companies already utilize sophisticated software powered by artificial intelligence, federated learning, and real-time data analytics to help them set their patient premium rates. They do so through the process called "price optimization." But, many people believe it's a way around risk-based pricing and a way to overcharge policyholders.

The Consumer Federation of America (CFA) and the Center for Economic Justice also dub price optimization "unfair and discriminatory."

Claims Data Is Valuable, Even More, Valuable To Insurance Industry

Claims Data is just as precious as gold has been for centuries. Everyone wishes to have it for free and sell it for a high price.

Data, in general, also comes with additional benefits to its beholder that are solely related to its nature. Data and information are also power. More of it you have, the more knowledge you possess over the rest of the others in the world; thus, you secure more control over them.

It is pretty understandable why insurance companies may be reluctant to play fair by holding to their end of the bargain. Yet still, that is not the primary issue.

Any information or data is the sole property of its contributor, not necessarily the property of its beholder. That is, unless the beholder has purchased such data from its original contributor. One can also speak for the Claims Data, where Insurance companies may or may not be their sole contributors.

The entire argument over the double standard in data sharing rests on the fact that it should not be a problem what, how, and who Claims Data or any other Data we share. But, the issue must reassure everyone that if you see the necessity of sharing or even exchanging data, then it must be exclusively between the owners of those data and their associated shared financial benefits.

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