How Data Sharing Is Transforming Healthcare Delivery

Healthcare innovation requires passion and a deep understanding of the industry’s complexities, which are often uncovered through diverse experiences.

On this episode of The Spark, Shruti Kothari, Director of Industry Initiatives for Health Care Reform at Blue Shield of California, discusses her experiences working in different areas of healthcare, from frontline care in underserved communities to driving innovation and policy at large organizations. She covers key priorities such as data sharing, payment innovation, and behavioral health integration, all of which aim to create a more efficient, equitable, and sustainable healthcare system. Shruti highlights the importance of collaboration between providers, health plans, and innovators to overcome barriers to scaling solutions. She also emphasizes the need for long-term, sustainable changes rather than short-term fixes and encourages a greater role for startups and venture capital in addressing systemic issues.

Tune in and learn how healthcare innovation is being reshaped to improve quality, access, and outcomes for everyone involved!

Evolving Healthcare Experiences: Andy Chu’s Perspective on Disrupting the Industry

A leader’s vision hinges on a solution-driven mindset, emphasizing scalability, platform-building, and aligning innovations with patient and provider needs.

In this episode, Andy Chu discusses his inspiring journey, insights on disruptive innovation, collaboration between payers and providers, and the vision of creating scalable platforms for transformative healthcare experiences. He also uncovers the critical vision driving the transformative work at Providence, focusing on scalability and positive impact across patients, providers, and financials.

Tune in for a thought-provoking discussion.

The New Role of Platforms and Networks in Driving Shared Value and Collaboration

So many digital startups have entered the market over the past decade that providers have become burnt out due to the noise caused by an overabundance of “point solutions.” But healthcare is complex for many reasons—fragmentation and misaligned incentives being two important ones. That’s why healthcare is now inundated with new products and services that don’t connect seamlessly with each other and may make fragmentation worse.

Seth Joseph, Summit Health founder and managing director, and frequent Forbes contributor, explains, “The challenge is no longer building software or apps for individuals. The opportunity now lies in connecting those individuals, and their systems, to facilitate new or more efficient interactions.”

In a recent Avaneer Health podcast, The Spark, Joseph suggests that what healthcare really needs is a way to better align constituents who have different priorities and incentives. “We need to build businesses that create value for solving two-sided problems where you can align incentives and deliver value on both sides.”

Misaligned Incentives in Healthcare

One of the best examples of misaligned incentives in healthcare is the complex exchange of data between payers and providers. Coverage verification is an excellent example. Individuals typically change employers or health plans, or have multiple lapses in coverage, several times throughout their lives. Even if they don’t change carriers, they may still experience benefit or network changes within their existing plans during annual open enrollment periods. It’s a problem that research shows can lead to hundreds of billions of dollars in administrative waste each year, most of it related to billing- and insurance-related activities.

The problem is that capturing and sharing updated coverage information has become extremely difficult for both payers and providers due to a lack of transparency and interoperability between their systems. For payers, this means they can miss secondary and tertiary coverage, causing them to pay for services that should have been covered by other plans. For providers, it means denied claims. In fact, incorrect or missing coverage information is one of the top causes of denied claims. Inaccurate data can also lead to delays in care or cause patients to have to pay for services that were covered.

This lack of transparency fuels friction and distrust. The good news is that platforms and networks have the ability to alleviate challenges like this by driving a new kind of innovation that aligns incentives and fuels transparency and trust.

The Value of Platform-based Solutions

In his recent Forbes article, Into the Death Zone? What Digital Health Can Learn From Epic’s $3.8B Revenue, Joseph says, “Platform businesses create value by bringing different constituents together and facilitating an exchange of value between them, not by selling software to either side.” He believes this is why innovative companies like Slack, Airbnb, and Uber have been so successful. They’ve leveraged platforms and networks to “drive growth, defensibility, and profitability.” They didn’t reinvent collaboration, travel, and vacationing; they just made those activities easier and more efficient—they added value to existing industries in a way that was mutually beneficial for all constituents. In the case of Airbnb, it added value for the homeowner and the consumer, not just for Airbnb.

Platform-Driven Approach to Innovation

Today, payers and providers have access to a new platform-based network that solves the issues of misaligned incentives and interoperability challenges. Avaneer Coverage Direct™ is the newest solution available on the Avaneer Network™, a digital network and platform that simplifies the business of healthcare. Designed as a modern IT infrastructure for sharing healthcare data, Avaneer Coverage Direct enables payers and providers to connect directly to facilitate timely, updated insight into a patient/member’s coverage information without the need to aggregate data or send it to third parties outside the network.

How it Works

Each payer and provider participating in the Avaneer Network receives a SparkZone™, which is their home base on the network. Once a participant loads their coverage information for their members/patients into their SparkZone, the Avaneer Coverage Direct process begins:

Data is transformed into common FHIR standards.

Data is seamlessly and securely transmitted directly between network participating payers and providers without third-party intervention.

Evaluation rules are applied to determine what coverage information between permissioned payers and providers is aligned or misaligned.

Coverage misalignment information can be auto posted into a participant’s internal system as an unsolicited push notification, available via API, or viewed in a portal.

One of the most significant benefits of Avaneer Coverage Direct is that it is purpose-built and use-case specific, bringing value for both payers and providers while improving transparency for greater trust and more aligned incentives.

Platforms and Networks, Not Just Software

Research shows that digital healthcare platform companies “grow faster, are more scalable, and more profitable than their software-only counterparts.” Creating more bolt-on technologies and software—no matter how innovative—can’t fix misaligned incentives or interoperability woes.

Avaneer Coverage Direct isn’t just another software solution designed to be added on top of existing systems. It’s a new way of conducting business that leverages a digital platform and network to address specific use cases and drive mutually beneficial, aligned incentives for payers and providers alike.

Innovation in Action: How Nashville General Hospital is Leading the Way in Health Equity

When we think of century–old health systems, we often think of slow-to-change organizations that follow the “because we’ve always done it that way” motto. They are so tied to maintaining the status quo that nothing changes unless forced. These organizations likely spend all their efforts on achieving and maintaining regulatory requirements, checking boxes on the Joint Commission survey, and keeping the doors open. However, one hospital is rewriting the rules and debunking this stereotype. The Nashville General Hospital leadership team has embarked on an inspiring transformation journey, challenging what it means to serve its community.

Challenges

For over a century, Nashville General has been a pillar of care and a beacon of hope for the Nashville community. Throughout its history, the hospital has served as a safety net hospital and is committed to providing care regardless of a patient’s ability to pay, which means it has had to rely heavily on state and local funding. Every improvement, expansion, new service, or update necessitates resource-intensive requests to local and state agencies, a testament to the challenges the hospital faced.

Another challenge the hospital faces is a lack of health equity among its patient population. Davidson County, where Nashville General is located, has the highest level of food insecurity in the state of Tennessee and more than 12% of the population find it difficult to access healthy food. Other social determinants of health (SDOH) like income, education, affordable housing, and access to transportation, also have a significant impact on Nashville General’s patient population.

An Innovative Approach

Dr. Joseph Webb, DSc, FACHE, who joined Nashville General as CEO in 2015, decided that caring for its population meant going beyond the hospital’s doors. He took an innovative approach to improving the health of individuals in the community by creating a holistic, proactive, patient-centered care model. The foundation of this effort was the Webb Health Equity Model (WHEM), a hub-and-spoke healthcare delivery process based on the “principles of evidence-based management.” Webb says that this evidence-based approach to care is statistically, scientifically, and empirically proven to produce desired outcomes.

As part of the Webb Health Equity Model, Nashville General implemented innovative initiatives like food pharmacies and faith-based community partnerships to address social determinants and barriers to care.

Food Pharmacy

Hippocrates is credited as saying, “Let food be thy medicine and medicine be thy food.” This is the underlying tenant in Nashville General’s “food pharmacy.” When patients enter the hospital, they complete a food insecurity survey. If they answer positively, the information goes into their patient record and to their provider who will write a prescription that is passed to the care team. The prescription indicates the patient’s conditions and what type of food they should receive. For example, someone undergoing cancer treatment will receive healthy, high-caloric food to keep them strong. Someone with hypertension or heart disease will be provided with low-fat, salt-free choices.

The food pharmacy is set up like a grocery store, with abundant fresh foods patients may not get in their local store. When they arrive, a dietician accompanies patients through the store, educating them about how to read labels, what to look for, and how to choose the food that will help them improve their health. Individuals stay in the program until there is a reasonable time to transition off.

A Faith-Based Approach to Health Literacy

Improving health literacy is essential for helping individuals understand how lifestyle and other factors impact their health. It is also vital for assisting them to better navigate our complex healthcare system. Webb reached out to faith-based organizations to help educate and support individuals where they live. As part of this effort, Webb established the Congregational Health and Education Network (CHEN)—a 501c3 that includes educational institutions and local faith-based organizations. The mission of CHEN is to reduce health disparities among Nashville’s African American community by elevating education attainment and health literacy through faith-based partnerships.

Webb says that African Americans, in particular, rely heavily on their faith-based organizations to meet their needs, whether social, economic, emotional, or psychological. CHEN helps improve health literacy and remove barriers, enhancing lives and delivering downstream benefits.

Learn more from Webb in an episode of The Spark here.

Results

Innovative initiatives like food pharmacies and faith-based collaboration act as “cost avoidance” programs by reducing medical consumption on the back end. Because of his forward-thinking approach, Webb has been able to create a more sustainable financial model that has allowed Nashville General to expand its services and reach even more Nashvillians. Additional achievements include the following:

Ranked #1 in Tennessee for health equity and inclusion by Lown Hospital Institute
Earned the Tennessee Center for Performance Excellence (TNCPE) 2021 Achievement Award
Earned 3-year full accreditation by the Commission on Cancer
Earned Joint Commission’s Gold Seal of Approval
Earned the highest recognition for Patient-Centered Care and Diabetes Care at its Internal Medicine Clinic

Innovation in Healthcare Delivery

Nashville General may be 134 years old, but it leads the way in innovation and accessibility. It has become an example for other hospitals wanting to break free of the status quo and create meaningful health improvements in their communities. It’s proof of what “innovation in action” truly means.

Sharing coverage data can be more secure with direct connections

I want to take this opportunity to announce that our initial solution has a new name: Avaneer Coverage Direct™. The new name more accurately describes the solution’s value: Connecting payers and providers directly, avoiding intermediaries, and closing the gap left by existing solutions (EDI, clearinghouses, and portals).

Enabling providers and payers to have a full view of coverage at the point of care, along with direct primary source updates, allows for improved patient/member experience and eliminates waste through the care continuum. Existing eligibility solutions miss key updates that lead to write offs, bad debt, and unexpected denials.

Avaneer Coverage Direct integrates with your workflow to ensure you always have updated information. There’s no swivel chair. Data remains under the control of the data originators in their private environment, and only exchanged between authorized participants. Person-level data is exchanged only when there is a match, instead of exchanging entire data sets.

I invite you to read our case study to learn more about the impact of Avaneer Coverage Direct or reach out if you have any questions.

David Schramm
Senior Product Manager, Avaneer Health

In This Issue

Putting the Value in Value-Based Care
Earth Day, hospitals and sustainability: ‘We’ve seen the momentum change’
Interoperability: some improvement, but much work remains
The Road to Building Trust in the Revenue Cycle

From the Avaneer Podcast

The Spark: Putting the Value in Value-Based Care

Bob Gross, executive director of financial decision support and analysis at Cleveland Clinic, and Krista Matlock, senior director of operations and market network services at Cleveland Clinic, discuss what puts the value in value-based care and how close we are to success. “The beautiful thing is that the technology, FHIR standards, and the data is here today.” Stakeholders are now coming to the table to discuss ways to create mutually aligned incentives that alleviate friction, reduce risk, and create a “harmonious member-centric experience.”

Listen to the podcast

Industry Highlights

Earth Day, hospitals and sustainability: ‘We’ve seen the momentum change’

Chief Healthcare Executive

Hospitals have come to realize that the Hippocratic Oath adage “First, do no harm” applies to the environment as well as to patients. A recent Commonwealth Fund survey found that 41% of hospitals have created teams focused on sustainability, or have assigned positions like chief sustainability officers while 24% said they plan to do so within the next three years. Hospitals are also finding that sustainability efforts can produce millions in annual savings. It’s a movement that executives, managers, and front-line employees are getting behind.

Read more

Interoperability: some improvement but much work remains

Medical Economics

How much progress has been made since the implementation of the 21st Century Cures Act in 2016 that sought to improve interoperability? That’s the question the American Board of Family Medicine asked more than 2,100 physicians in a recent survey. Just 10% of respondents said they were satisfied with the progress. This insightful article breaks down the complete survey to offer insight into just how far we have yet to go to achieve “universal, high-value interoperability.”

Read more

From the Avaneer Blog

The Road to Building Trust in the Revenue Cycle

Effective relationships are built on trust, transparency, and a shared vision that leads to mutually beneficial outcomes. If we remove those attributes, each party prioritizes their own interests, often at the expense of the other party. Such is the case with payers and providers. Although they do business together, a lack of aligned interests has led to friction that significantly disrupts the revenue cycle and patient care. But that’s about to change as new solutions enable a trust-filled, patient-centric future that benefits all parties equally.

Read the blog

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