NaviNet on March 25, 2015

Will Today’s Payer Have the Role they Want Tomorrow?

Frank Ingari, President & CEO, NaviNet, Inc.

Healthcare reformers tend to split on the question—some imagine a world in which clinical integration among EMRs and providers will provide all the insight necessary to achieve the Triple Aim, reducing the payer to a kind of generic third-party administrator focused on stripped-down administrative tasks in support of risk-bearing delivery systems.

Others see the enlightened payer working in close collaboration with a heterogeneous clinical community, functioning as the best-equipped supplier of evidence-based guidance and a central participant in value-based coordinated care.

In my opinion, the answer to this question will shape the pace and scale of successful reform. From NaviNet’s perspective as the nation’s largest Healthcare Collaboration Network connecting payers and clinicians, we see payers making tremendous investment in funding, developing, and evolving clinical connectivity as a part of redefining what is “administrative” and what is “clinical.”  

Perhaps more importantly, we see providers adopting population health and clinical programs funded and enabled by their contracted payers, broadly and at an accelerating pace. NaviNet is already working with several major payers who are connecting their own self-funded regional HIE investments to the NaviNet Healthcare Collaboration Network to ensure, for example, that the referral approval process is integrated with the clinician-to-clinician information exchange process.

Seen in this light, the Office of the National Coordinator for HealthIT's (ONC’s) recently published “Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap” presents payers with an interesting dilemma.

On its face, the ONC Roadmap seems to adhere to the longstanding position of many theoreticians that reform depends largely on what happens to “purely clinical” information that passes among providers. Despite the assertion that the ONC vision “significantly expands the types of information, information sources and information users well beyond clinical information derived from electronic health records (EHRs),” the Roadmap defers consideration of the payer’s role: “The intersection of clinical and administrative electronic health information is a critical consideration, but is out of scope for the Roadmap at this particular time.”

Given the critical importance of provider adoption to getting real results from reform investment, kicking this particular can down the road may prove problematic.  

Insiders say that the ONC understands how important the integration of reimbursement-oriented processes will be to achieving truly fluid clinical information flow, but that it chose to focus the Roadmap on what it sees as the central and blocking task— getting EMR vendors to play nicely by providing a combination of pressure and a potent new technology asset in Fast Healthcare Interoperability Resources (FHIR). This could work, although the pressure may be blunted significantly if MU3 does not grow sharp teeth.

On the other hand, given the lengthy time frames of the Roadmap, is it really sensible to defer the question of administrative/clinical integration for three, five, or even ten years?


Evidence suggests that such delay may avoid the use of the most potent tools of all. Payers already have amassed significant stores of claims, pharmacy benefit manager (PBM), and lab data and invested in the big data systems, tools, and informatics staff to manage and harvest them. As payers increasingly integrate EMR, HIE, and consumer data into these massive warehouses, who will be better equipped to provide the best population health guidance, tailored to the specific patient, and connected to reimbursement incentives based on the Triple Aim?

Connecting clinical workflows to eligibility, benefit, and patient financial responsibility detail; to referral and authorization processes; and to the emerging class of population health campaign and value-based incentive management software will likely emerge as the most effective vehicle of all for moving the interoperability dial ahead smartly.

So…was the deferral of administrative/clinical workflows from the Roadmap an honest effort to focus on EMR-EMR connectivity, the deferral of which may or may not turn out to be a tragic mistake? Or was it a more calculated “head fake” intended to keep payers out of the guts of clinical reform?

It appears to me that at times over the past decades, payers have been willing to sit back and watch provider-centric reform movements grind along at a snail’s pace. Reform today is a different animal: It is driven by fundamental economic forces in government, business, and consumer culture. It may be time for the enlightened payer to push forward into the heart of interoperability by advocating its ability to present the best data—population-level insights and current, patient-specific information—embedded in workflows that are connected to reimbursement and cross the chasm between the “administrative” and “clinical.”

Leadership at the ONC supports publically the view that “market forces” are the best predictors of success for reform. I believe that payers should pay attention to the Roadmap and begin to advocate more forcefully for the constructive and powerful “market force” role they are already playing in the movement toward clinical interoperability. They should consider joining industry initiatives like those identified in the Roadmap (e.g., Argonaut) and push for a seat at the table with government policy leadership.

If you are interested in exploring or debating these ideas, download our new webinar, or contact me at

Tags: Healthcare IT

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