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Usinga blockchainto reimagine how healthplans manage physician
identity information
This point of view representsa thought...
Despite providersmaintaining affiliationswithanaverage of20healthplansat a giventime, healthplansrarelycollaborate onPDM.T...
FromSeptember2016toAugust2017, theCenterforMedicareand
MedicaidServices(CMS) completedits secondroundof provider
directory...
Validated changes are accepted by the Buyer and the
fee, held inescrow, ispaid to the Seller.
Health plans or other compan...
Siloed Records
Current Challenges
Multiple health plans are maintaining
often conflicting records for the same
National Pr...
Automation People/Effort Costs& Incentive
Models
Intelligence &
Analytics
► Smart Contracts
► More payments,
processes and...
“Experimentation”
“Incentivized
Crowdsourcing”
“Dynamic
Marketplace”
► Proofsof Concept–
validate technology and
determine...
Provider
data
becomes
an asset
Qualitative
Measure
Quantitative
Measure
+
A marketplace for provider data – Using blockchain to reimagine how health plans manage physician identity information
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A marketplace for provider data – Using blockchain to reimagine how health plans manage physician identity information

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This deck was co-presented with Humana at the EY Global Blockchain Summit on April 18, 2018 as part of the Sector Track.

Published in: Technology
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A marketplace for provider data – Using blockchain to reimagine how health plans manage physician identity information

  1. 1. Usinga blockchainto reimagine how healthplans manage physician identity information This point of view representsa thought leadership effortcompletedbyHumana and EY, it doesnot reflectthepoint of view of any specificalliance, collaboration or consortiumHumana is participating in.
  2. 2. 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. Humana Payer 3 Payer 2 Payer 4 ManualOutreach Centralizationthrough third parties Widespread Duplication ► Everyquarter,thehealthplanreaches outto theirnetworkproviders via phone,faxandmail. ► Mostproviders donotunderstand the importanceofproviderdataand therefore andarenotactively engaged inmanaging theirowndata. ► Onaverage, Humanamustmake seven(7) attemptsatcontacting the providerbeforereceiving an attestation. ► Dueto theamountof manualeffort required tomaintainprovider data, Humana outsources aportionofthe provideroutreachfunctiontothird partyvendors ► Humanasends a provider roster to thevendorsasneeded andpaysafee foreachupdated record ► Healthplansareperformingthe sameoutreach andmaintenancefor an overlappingsetofproviders. ► Thisleadstobotheffortsandcosts beingduplicated across theindustry.
  3. 3. FromSeptember2016toAugust2017, theCenterforMedicareand MedicaidServices(CMS) completedits secondroundof provider directory audits. The review examined 6,841 providers at 14,869 locations across the online directories of 64 Medicate Advantage Organizations (MAOs) 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 inaccuraciesincluded:  Provider was not at the location listed  Phone number was incorrect,or  Provider was not accepting new patients
  4. 4. 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 4 Health plans provide marketplace inventory Sellers “shop”the marketplace for out-of-date records Proposed changesare not assumed to be true Sellers receive a per-recordreward for providing updates 1 2 3 A Provider Data Marketplacecould functionas follows:
  5. 5. Siloed Records Current Challenges 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. Duplicated Effort Transparent Market 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. CrowdsourcedMaintenance 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 contracted with. Few Data Sources(Centralized) Marketplace Advantages Health plans view provider data management as a cost center and not a revenue generating function. Cost Center Provider data becomes an asset that health plans can monetize on the marketplace. Data as an Asset
  6. 6. Automation People/Effort Costs& Incentive Models Intelligence & Analytics ► Smart Contracts ► More payments, processes and workflows will become automated ► Thereplacement of trusted third parties with trusted networks will change industry cost structures ► New incentive models will emerge ► With more automation, less people will be needed to perform tasks ► Certain functions may be eliminated entirely ► Access to and transparency of data ultimately means better analytics ► Everyone will have a wealth of new information at their fingertips
  7. 7. “Experimentation” “Incentivized Crowdsourcing” “Dynamic Marketplace” ► Proofsof Concept– validate technology and determine value proposition ► External Simulations– refine functionality and user experience; coordinate market simulations with overlapping networks ► 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- marketplace payment mechanism
  8. 8. Provider data becomes an asset Qualitative Measure Quantitative Measure +

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