7 ways your health plan is holding your data hostage

Do all self-insured employers and other health care purchasers enjoy sufficient access to their health care data? Unfortunately, the answer is a resounding no.

Data helps purchasers evaluate their current health care offering, tweak an existing program and/or implement new, innovative strategies. But in recent years, certain claims and clinical data have become serious currency in health care, and as such, health plans have increasingly treated this information as an asset to be monetized.

Related: Legacy data warehousing’s dirty little secret

Plans may hold valuable data hostage or erect speedbumps to impede flow to a purchaser and/or its other business associates that supply supporting services. Plans consider data requests on a case-by-case basis, and commonly, base decisions on whether to comply on what is best for them not their purchaser clients.

The employers and other purchasers who succeed in securing ownership, access to, and use of their data fall into a few categories: geographically concentrated jumbo purchasers with market leverage; large purchasers at-risk of switching plans; or self-insured purchasers with a desirable logo. All other purchasers, unless they have preemptively negotiated principles of data stewardship into their health plan and vendor contracts, will likely face painful, drawn-out negotiations.

Over the past year, Catalyst for Payment Reform researched purchasers’ data challenges, identifying the seven most common defenses that health plans deploy to restrict purchasers’ access, use and ownership rights:

1. “I can provide you with most of these data … but not all of it.”

Health plans are reluctant to provide data that allows purchasers or their business associates (such as a point solution vendor) to calculate provider discounts or create products that steer plan members to certain network providers. Plans still view their provider network and negotiated discounts as proprietary, even though federal price transparency regulations now open the black box on these data.

2. “The data are proprietary now that we’ve processed it.”

Whether health plans have developed a proprietary algorithm or analyzed the data to produce a report, they view claims and clinical data as theirs once they have processed those data in some way.

3. “We cannot share that dataset because it relates to sensitive conditions.”

Primarily with regards to behavioral health, HIV, and genetic testing, plans may erect barriers to data about the claim or encounter transaction, limiting a purchaser’s ability to design appropriate interventions to support plan members with certain conditions.

4. “We can’t share the data with that vendor because they are a competitor of ours.”

Plans may view navigation or transparency vendors as competitors. Furthermore, plans may have preferred vendor partnerships with pre-negotiated pricing and established data integrations, limiting the purchaser’s ability to bring in their preferred partner.

5. “The data use agreement does not cover your entire request. We’ll need to execute another one.”

Plans may weaponize agreements to slow or stymie the data-sharing process. By requiring a new use agreement for every data transaction, health plans hope to wage a war of attrition by raising the required cost and effort.

6. “It will take us ‘x’ weeks to program the report you’re asking for.”

Another way plans sandbag the data sharing process is by taking so long to fulfill the purchaser’s data request, long past its useful shelf life.

7. “We’ll look into why the data in the file you received is incomplete and/or inconsistent.”

Even when health plans provide the requested data file, that doesn’t guarantee the data are accurate or complete. This calls into question the plan’s quality control process and further delays the utility of the data.

What can purchasers do to break the data gridlock?

During a marketplace evaluation or competitive bid process:

• Elevate your ownership of claims and clinical data as a contracting requirement.
• Obtain the plan’s commitments to give you data access and use by asking data-related questions.
• Reframe the conversation. Link your specific claims and/or clinical data request to how the data will help you fulfill your plan fiduciary obligation.
• Openly discuss with other employer-purchasers the barriers you encounter and the successes you have had in negotiating data acquisition and use.

With these actions, whether you work for Jumbo, Inc. or Little Company, LLC, you can unlock your data to fulfill plan fiduciary obligations and offer high-value benefits to your plan members.

Ryan Olmstead is director of member services Catalyst for Payment Reform.