Leading health plans say provider data management is the key to value-based care and member satisfaction

In collaboration with Becker's Payer, Ribbon Health led a roundtable discussion with key health plan executives to explore how better data management can lower costs and improve member outcomes

In a recent survey of consumers, 66 percent of participants indicated that access to more accurate provider information would increase their trust in their health plan.

Provider data management is a crucial function for health plans, but it's also a challenging one, since every year 30 percent of provider data churns.

At Becker's Hospital Review's 2023 Payer Issues Roundtable, Ribbon Health led an executive roundtable to explore how better data management can lower costs and improve member outcomes. Elizabeth Duffield, enterprise sales director at Ribbon Health, facilitated a discussion with four healthcare leaders:

• Fay Rotenberg, chief executive officer, Firefly Health
• Ninad Umrani, general manager and staff vice president, provider network management, Carelon Digital Platforms, Elevance Health
• Ben Kowitt, MD, leader of clinical product, Surest
• Nate Maslak, chief executive officer, Ribbon Health

There were five key takeaways:

1. When it comes to provider information, organizations need a single source of truth. Providers are responsible for managing their own data records. As a result, data lags are common and information isn't published transparently or in a standard format. "With all the changes recently in price transparency laws, there is a lot more data available," Ms. Rotenberg said. "But it's challenging to know how to use it, as well as how to verify it and make sense of it. Our core business isn't provider data management, so it's a huge tax on our organization." Firefly Health gets as much data as possible from Ribbon Health and uses it to inform member navigation. ‍
2. Provider data is the lifeblood of a payer's business. Surest, for example, is a copay-only plan designed around transparent, up-front pricing. Provider data is crucial when members shop for care and confirm prices in advance. "The information goes beyond a standard directory," Dr. Kowitt said. "The provider has to be in-network and claims on the back end must adjudicate to match the quotes provided to members on the front end."‍
3. Without correct provider data, value-based care is difficult to deliver. With capitated payment arrangements, each member's primary care physician must be identified accurately. "When you think about value-based care, you must attribute a member to a provider," Mr. Umrani said. "If the provider information is wrong, it directly impacts our ability to drive value from that model. It also affects authorizations, customer service, provider service, network adequacy, analytics, provider profiling and more."‍
4. To improve provider data accuracy, health plans are using metrics. "We can solve provider data accuracy issues if we take a digital-first approach. This means focusing on the consumer and working backwards. Metrics must be consumer-centric, such as reducing authorization issues, out of network issues and claims accuracy issues," Mr. Umrani said. In addition to standard metrics like completeness and accuracy, Surest has implemented a unique metric called "quote to claim accuracy."
5. ‍Health plans rely on provider data for fast, seamless member navigation. When Firefly Health has access to reliable data about the provider network, demographic and insurance information, it can make member referrals more rapidly. "Our ability to send people to higher-value providers is a huge factor in our ability to decrease total medical expenses," Ms. Rotenberg said. "On average, we are reducing TME by 18 percent. One of main drivers is unit cost — it's all about quickly navigating members to the right providers."

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