All Articles Healthcare Insurers Better payer-provider data sharing improves the member experience


Better payer-provider data sharing improves the member experience

How health plans’ data strategies can improve patient care

5 min read



As health plans increase their focus on consumer-oriented data strategies and invest in new technologies, plan leaders need to collaborate with other stakeholders to streamline these changes. Recently, SmartBrief spoke with Tyler Ford, vice president of strategy and partnerships with the Council for Affordable Quality Healthcare (CAQH), about health plans’ data challenges and strategies.

What are some trends you’re seeing in health plans’ data strategies?  

One clear trend is the laser focus that health plans have on improving the member experience.  We’re hearing that plan sponsors – both public and commercial – are increasing their expectations when it comes to the services and information members have access to when making decisions.  Plans are building out data strategies with a more consumer-oriented framework.  That means new investments in price transparency or cost estimation, patient ratings and feedback, and even prescriptive guidance or recommendations.

Separately, on the technical level, we continue to see considerable investment in data integration and interoperability. Plans are seeking a more consolidated, enterprise view of data that can serve a variety of needs with more consistency. Although they will achieve results at a varying pace, most are building much more consolidated and member-focused data enterprises.

What’s the most important issue health plan leaders should devote more attention to?

I think health plan leaders should be attentive to the way their organizational strategies influence the provider community to scale up. A great illustration of this is efforts to embed more clinical guidance and payment information into provider workflows. One example is giving prescribers access to their patient’s out-of-pocket estimates for clinically equivalent drugs at the point of care. That effort – to provide more information to providers natively at key moments in the care process – can become incredibly complex when providers must account for customization across individual payers or plans. In many cases, there’s likely opportunity for more alignment across plans on these efforts than leaders may appreciate.

Without more intentional coordination across health plans (and IT vendors), providers won’t have the capacity to manage so many cost and quality initiatives. Health plan leaders can address this by actively working to understand where they can partner with other stakeholders in the space to streamline or cut down on the distinct number of initiatives or asks being put on providers.

We’ve heard a lot about payers vertically integrating with providers. How does that affect CAQH’s role in the industry?

The first thing we’re doing is helping with the change management that comes with operational integration. Very often, merger activity between plans and providers outpaces those organizations’ ability, or even desire, to integrate their operations. Plans want to be intentional and deliberate about integration.

Because most US providers work with CAQH to share information with their designated plans, we’re working with our health plan partners to integrate the data they need. It’s important that we continue to leverage the platforms and processes those providers are already using instead of introducing new technology and vendors, and adding more complexity.

The second initiative we’re supporting is trying to avoid a shift where access to provider data becomes an area of competition in healthcare. We believe that members of every health plan need complete, accurate information on providers in their market to help choose the care that’s right for them. We also believe that providers deserve oversight and engagement when it comes to decisions and use cases that use their information. That’s why our model is based on consistency from data collection, aggregation, and sharing across organizations and provider engagement – a critical foundation for information exchange.

What are the major policy or regulatory issues CAQH is tracking right now?

CAQH closely tracks a wide spectrum of state and federal policy issues affecting plans and providers, and this year, we’re closely watching regulation around provider directories and network adequacy.

In directory regulation, we’re noticing state activity aimed at increasing directory accuracy that’s either enhancing or augmenting data requirements already required by federal mandates. That’s notable because we expect these actions to make navigating an increasingly complex patchwork of requirements even more challenging.

Across adequacy, plans face challenges with respect to complying with the new and varied network adequacy requirements. This is due not only to provider shortages, geography and contracting challenges but also because of the inconsistencies between federal and state requirements, and variation between market segments.

What are you most excited about this year at AHIP 2023?

We’re most excited for the diversity of perspectives a conference like AHIP brings, especially among this year’s speakers and attendees.  The conference has done a great job of creating an agenda that fosters dialogue around how policy, business, technology, equity and social interests converge in healthcare.

It’s also wonderful to network and engage in person after several years of remote and digital attendance. For many of our staff — and others, I’m sure — it’s one of the first opportunities to gather in person with industry peers and colleagues.

Tyler Ford is the vice president of strategy and partnerships at CAQH, where he’s responsible for identifying growth and innovation opportunities aligned with CAQH’s mission through new payer-provider data solutions and corporate partnerships.  Ford’s focus is on collaboratively engaging health plans, providers and innovative companies to build the next generation of solutions and initiatives to streamline avoidable administrative costs across healthcare. Prior to CAQH, Ford held senior-level strategy and product roles at UnitedHealth Group and the Advisory Board. He is a graduate of Dartmouth College (BA) and the University of St. Thomas (MBA).