Electronic Health Reporter

By Don Rucker, MD, chief strategy officer, 1up Health

Medicare Advantage is a capitated health plan and the government, which pays for the plan, needs massive amounts of performance data to ensure that plans do right by patients and don’t scrimp on care. With capitation’s pre-determined payment rates, there is an incentive to do less.

The main tool CMS has to monitor performance is the Star Ratings system (though there are lots of other regs to be sure with this as a goal). The data needed to optimize Star Ratings is what fuels the revenue cycle stack in MA plans. In 2025, health plans must

How do these MA payment policies force a rethink about data and technology?

Star Ratings measures of clinical and customer plan performance are reported, then scored and rolled up into overall scores by CMS.  These are used to set MA plan, bonuses, other payments and are also reported to patients when they are choosing a plan. This incents two large patterns of behavior – one is to get the underlying data to show performance and the other is to improve that performance. Historically, quality measurement has involved lots of manual steps and even today some data is based on chart pulls and having humans read EMR computer screens. The modern world, a decade of EMR incentives, and modern APIs provide starkly different options to get and improve plan performance data.

Are classic claims dataflows enough or will payers need rich clinical data to succeed?

Not surprisingly, most of the measures deal directly with clinical performance. Today much of Star Ratings scoring is based on claims data – increasingly the winners will use clinical data both to measure performance and to improve performance. It is important to understand the scores are relative – if a plan uses more clinical data and gets a better score that means the plans that don’t use clinical data are more likely to get a lower score. Economists describe this as a “zero-sum game.”

How can plans think about getting clinical data?

Obviously clinical data is captured and stored in EMRs. Certified EMRs are now required to have both patient access APIs as well as Bulk FHIR APIs. Bulk FHIR APIs allow the US Clinical Data for Interoperability (USCDI) to be obtained by the payer from the provider EMR in one swoop if the provider and the payer can reach a satisfactory agreement to share this data in their network contract.

Is getting clinical data enough?

No. It is not just about documenting today’s clinical performance. While that is a large step, the key differentiator will be doing something to improve that performance.

What does a modern digital strategy look like? 

A modern digital strategy, whether it is a merchant like Amazon, a service provider like a bank or airline, or a media company, relies on easy access to websites via smartphones and targeted outreach via messaging or email timed to optimize success. For payers that means thinking about what to “say” to patients and providers and how to “hear” from patient and provider feedback, device monitoring data, and clinical data. That is what APIs enable.

How do modern tech data stacks fit into successful payer data landscapes?

Over the last three decades the workhorse of data storage and action has been the relational database. With modern Internet paradigms, newer and faster data stores, in particular the No-SQL databases, have emerged. However, data stores are being increasingly used throughout the tech industry to combine structured and less structured data in joint locations, optimizing all aspects of analysis and outreach.

Often these are known as “Lakehouse” architectures – the data lake and data warehouse providing an illuminating portmanteau. There is every reason to suspect this architecture, which supports high performance real-time and near real-time computing as well as more classic hypothesis driven analytics, will be the underlying platform for any payer who wishes to win in our data-driven capitated payment world in the coming years.