A marketplace for provider data – Using blockchain to reimagine how health plans manage physician identity information
Usinga blockchainto reimagine how healthplans manage physician
This point of view representsa thought leadership effortcompletedbyHumana and EY, it doesnot
reflectthepoint of view of any specificalliance, collaboration or consortiumHumana is participating in.
Despite providersmaintaining affiliationswithanaverage of20healthplansat a giventime, healthplansrarelycollaborate onPDM.Thisresults inthe
duplicationofmaintenance costsandeffortsacrosstheindustry.Today, eachhealthplanmaintainsitsownsource oftruth,anddirectlyperformsprovider
outreach toverifythedataand/orpurchases updated datafromathirdparty.Currently, thereisnoeasywayforhealthplansto collaborateonthe
maintenance ofasinglerecord, andnosetofattestation oroutreachstandards thatwouldallowahealthplantotrustanotherplan’smaintenance efforts.
ManualOutreach Centralizationthrough third parties Widespread Duplication
outto theirnetworkproviders via
► Mostproviders donotunderstand the
engaged inmanaging theirowndata.
► Onaverage, Humanamustmake
seven(7) attemptsatcontacting the
► Dueto theamountof manualeffort
required tomaintainprovider data,
Humana outsources aportionofthe
► Humanasends a provider roster to
beingduplicated across theindustry.
MedicaidServices(CMS) completedits secondroundof provider
The review examined 6,841 providers at 14,869 locations across
the online directories of 64 Medicate Advantage Organizations
CMS found that 52.2% of the provider directory locations listed
had at least one inaccuracy.
The first round of CMS audits were conducted from September
2015 to August 2016, where it was found that approximately 45%
of provider directory locations listed had at least one deficiency
The most common
Provider was not at the
Phone number was
Provider was not
accepting new patients
Validated changes are accepted by the Buyer and the
fee, held inescrow, ispaid to the Seller.
Health plans or other companies needing accurate
provider data (Buyers)setdemand inthe
marketplace by proposing areward per record for
updates from other market participants.
Third party data sources (Sellers)willmonitor the record
pool onthe marketplace and propose updates to out-
of-date records. Health plans and Providerscould also
serve as Sellers.
Buyerscan reviewproposed changes from Sellers,but
Buyerscan require that proposed changes be
Health plans provide marketplace
Sellers “shop”the marketplace for
Proposed changesare not assumed
to be true
Sellers receive a per-recordreward for
A Provider Data Marketplacecould functionas follows:
Multiple health plans are maintaining
often conflicting records for the same
National Provider Identifier (NPI).
Despite a provider on average being affiliated
with up to 20 health plans at once, each
health plan maintains a separate provider
record, and performs quarterly outreach to
verify the data.
A marketplace will allow health plans and other third
parties to come to a consensus on a single record that
is held to be the truth for each NPI.
The proposed marketplace will enable health plans
to stop maintaining provider data in their own silos
and distribute effort and cost across the industry to
curate a more accurate provider directory.
ManyData Sources (Distributed)
Health plans have the flexibility to purchase from as many
or as few Sellers as they wish. Because the health plan is
not locked in to a certain party, they have the ability to
make real-time purchase decisions based on market price
and seller credibility.
Currently, health plans only have access to
data from their own internal outreach as
well as the third party vendors they are
Few Data Sources(Centralized)
Health plans view provider data
management as a cost center and not a
revenue generating function.
Provider data becomes an asset that health plans can
monetize on the marketplace.
Data as an Asset
Automation People/Effort Costs& Incentive
► Smart Contracts
► More payments,
of trusted third
► New incentive
► With more
people will be
needed to perform
► Certain functions
may be eliminated
► Access to and
► Everyone will
have a wealth of
new information at
► Proofsof Concept–
validate technology and
determine value proposition
► External Simulations–
refine functionality and user
market simulations with
► Pilots– fixed-length market
tests with live data is specific
geographic locations to
determine impact on data
quality and cost savings
► Limited Launch– Live
marketplace with pre-
approved list of health plans
and data providers
► ExpandedOffering– Live
marketplace with open
enrollment for new health
plans and data providers;
dynamic pricing; reputation
system for data providers; in-