Healthcare Analytics, Population Health Management, Healthcare Big Data

Population Health News

Will better analytics drive payers to drop trouble providers?

By Jennifer Bresnick

- Nearly 100 providers in Rhode Island have a big problem on their hands.  UnitedHealthcare of New England has decided to eliminate dozens of physicians from the payer’s Medicare Advantage offerings, leaving thousands of elderly patients without coverage at their primary care and specialist sites.  While UnitedHealthcare has not said specifically that the changes are part of an effort to eliminate costly patients in need of extensive care, many providers affected by the cuts are wondering if UnitedHealthcare is making a calculated move based on population health statistics intended to help patients, not hurt them.

The payer isn’t saying much about its reasons for the change, according to the Providence Journal. Steven R. DeToy, spokesman for the Rhode Island Medical Society, says the health plan is targeting small groups across a variety of specialties, some of whom have not yet adopted EHRs.  While UnitedHealthcare says that they are simply trying to create “a network of physicians who we can collaborate with to help enhance health plan quality, improve health care outcomes, and curb the growth in health care costs,” it seems a little suspicious that they are effectively pushing out elderly and sick patients, many of whom will need to jump to one of their major competitors, BlueCross BlueShield of Rhode Island, if they want to keep their providers.

A statement from UnitedHealthcare said that patients are free to continue seeing their providers on an out-of-network basis, a very expensive proposition for retirees on fixed incomes.  “Our patients are freaking out. Literally, there was a woman shaking,” said Dr. Lynn Iler, an East Greenwich dermatologist who treats many elderly patients with recurring skin cancers.  A number of her patients will likely make the switch to Blue Cross, she says, foisting the costs onto them.  “So Blue Cross loses and United wins.”

The move has caught the attention of federal regulators after complaints by physicians, with the Office of the Health Insurance Commissioner promising to look into the behavior.  “They look at your patient mix,” said Newell E. Warde, executive director of the Rhode Island Medical Society. “They’re not just dumping doctors. They’re dumping patients. These may be expensive patients.”

While the Affordable Care Act prevents insurers from dropping sick patients due to the costs they incur, the increasingly ability of payers to look at populations on a geographical and demographic level can help them pinpoint providers who serve a large proportion patients with the highest costs.  As the number of older Americans with chronic conditions and complex needs increases, will health plans use the power of their population health analytics to make a quick buck by trim troublesome providers instead of developing theoretical cost-saving measures like preventative services, community care, medication adherence, and care coordinators?

It’s a worrisome thought, and it’s one of the reasons that providers are deeply concerned about letting payers access the data that they’ve been working so hard to collect.  “It’s a political dance, because my sources of data, which are physician practices and hospitals, are a little more wary of how much access the payer community might have to their data,” says Dev Culver, CEO of HealthInfoNet, Maine’s statewide health information exchange (HIE).  “I think we have a lot of history to overcome, and I think that the move towards risk-based contracting is actually aligning the incentives between those two communities much more tightly.”

But actions like those taken by UnitedHealthcare may not do very much to bolster the fragile trust, especially because the payer has been sending out the same notices to thousands of providers in other states, as well.  Providers might not see much of a point in collecting population health data if it’s just going to be used against the patients they serve.  “I’d be less than honest if I told you there’s a great agreement of minds here,” says Culver.


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