Health plans can gain efficiencies and improve quality by connecting to health information networks and incentivizing hospital and provider participation as part of pay-for-performance programs.
Am J Manag Care. 2022;28(12):e426-e427. https://doi.org/10.37765/ajmc.2022.89277
Health plans, hospitals, and providers are increasingly recognizing that sharing claims and clinical data can help them coordinate care, reduce costs, manage population health, improve patient experience and outcomes, and address health equity challenges—in short, tackle many of the toughest challenges in health care.
To incentivize and encourage health care providers to share health information, Inland Empire Health Plan (IEHP), one of the 10 largest Medicaid health plans and the largest nonprofit Medicare-Medicaid plan in the country, has taken an innovative approach to include financial incentives for sharing health data in its quality pay-for-performance (P4P) programs that reward hospitals, primary care providers (PCPs), and independent practice associates (IPAs) for high-quality care.
IEHP proudly serves more than 1.6 million residents of Riverside and San Bernardino counties in California and nearly 90% of the Medi-Cal (California Medicaid) enrollees in the region. The plan is highly committed to providing “optimal care and vibrant health” and launched its second-generation quality P4P programs in 2016 to provide financial rewards to PCPs and IPAs for improving health care quality across multiple domains, including clinical quality, access, behavioral health integration, and patient experience. In 2018, IEHP launched its Hospital P4P Program,1 providing financial rewards to hospitals that meet quality and performance targets and demonstrate high-quality care to members.
One key component of the Hospital P4P Program is incentivizing active data sharing with Manifest MedEx, a statewide nonprofit health data network, to improve care coordination between hospitals and community care. The health data network alerts providers when patients have a hospital encounter and need effective postdischarge follow-up. It also facilitates the sharing of longitudinal patient records among the care team, integrating health information such as test results, prescribed medications, and other clinical and claims data from participating health care entities so that care team members get a more complete picture of a patient’s health.
The P4P requirements have led to rapid increases in data sharing in the Inland Empire region, where today there is near-universal data sharing among hospitals and IEHP. More recently, IEHP has focused on improving completeness and quality of data from hospitals. To qualify for incentives, hospitals must share data and meet data quality requirements in 4 areas: admission, discharge, and transfer data; observational results data, such as laboratory orders and laboratory results; pharmacy/treatment encoded orders, such as prescription orders; and vaccination record updates. In 2020, 67% of targets for data quality and completeness were met by IEHP’s participating hospitals. The health plan aims to increase this performance to 90% by 2024 by providing timely and actionable data quality feedback reports to hospitals. Better-quality data shared through the health data network translates to streamlined inpatient care processes that better support members.
Hospitals also benefit from the financial incentives for active data sharing in addition to the many other benefits of sharing health data, such as improved care coordination and emergency department efficiency. IEHP’s annual budget for the 2021 Hospital P4P Program was $31.5 million in total possible payouts to qualifying hospitals that meet quality performance targets, with $6 million allocated to active data sharing with the nonprofit health data network. In the first quarter of 2021, hospital participants earned around $46,000 each per quarter for the active data-sharing measure, depending on their performance and the number of IEHP member admissions.
For 2022, IEHP added data-sharing requirements to the PCP and IPA P4P programs in recognition of the fact that data sharing and the care coordination that it enables are critical foundations of high-quality care. IEHP will also explore how to improve the plan’s ability to collect patient race and ethnicity data that are available from hospital data connections. These data will help support IEHP’s health equity initiatives including the identification and reduction of health disparities.
The extension of data-sharing incentives to PCPs also aligns with a California Department of Health Care Services program called California Advancing and Innovating Medi-Cal (CalAIM).2 CalAIM’s goals include improving the quality of outcomes for patients by reducing health disparities and focusing on value-based care. Health plan incentive payments will be based on several performance measures, including the percentage of enhanced care management and behavioral health providers that share care plans and clinical records with the care team.3
IEHP is not alone in adopting data-sharing incentives as part of broader quality improvement programs. Blue Cross Blue Shield of Michigan requires data sharing with Michigan Health Information Network as part of its P4P program.4 States are also taking this approach. Arizona Medicaid’s Differential Adjusted Payment program5 gives hospitals up to a 2.5% payment increase for sharing data with the statewide health information exchange, Health Current. In 2021, Wisconsin also launched data-sharing measures as part of its Medicaid P4P program for hospitals,6 allotting $8 million for 150 hospitals to share clinical data with the Wisconsin Statewide Health Information Network. These programs have demonstrated that financial rewards are a critical strategy in building vibrant, working health data ecosystems among partners with the shared goals of improving quality of care, better coordinating care, and reducing readmissions.
Author Affiliations: Inland Empire Health Plan (EJ), Rancho Cucamonga, CA; Manifest MedEx (EG), Riverside, CA.
Source of Funding: None.
Author Disclosures: Dr Juhn is an employee of Inland Empire Health Plan, which operates an incentive program to financially incentivize hospitals and providers to share data with Manifest MedEx. Ms Galvez is an employee of Manifest MedEx.
Authorship Information: Acquisition of data (EG); drafting of the manuscript (EJ); critical revision of the manuscript for important intellectual content (EJ, EG); and administrative, technical, or logistic support (EJ, EG).
Address Correspondence to: Edward Juhn, MD, MBA, MPH, Inland Empire Health Plan, 10801 6th St, Ste 120, Rancho Cucamonga, CA 91730. Email: email@example.com.
1. P4P - Proposition 56 - GEMT: Hospital P4P Program. Inland Empire Health Plan. Accessed December 15, 2021. https://www.iehp.org/en/providers/p4p-prop56-gemt#P4PHospital
2. CalAIM. California Department of Health Care Services. Accessed December 15, 2021. https://www.dhcs.ca.gov/CalAIM/Pages/calaim.aspx
3. California Advancing and Innovating Medi-Cal incentive payment program. California Department of Health Care Services. October 27, 2021. Accessed December 15, 2021. https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2021/APL21-016.pdf
4. Blog: building a statewide HIE network in months—not years. Connecting for Better Health. Accessed December 15, 2021. https://connectingforbetterhealth.com/updates/blog-building-a-statewide-hie-network-in-months-not-years/
5. Differential Adjusted Payment (DAP) program CYE 2023. Health Current. Accessed December 15, 2021. https://healthcurrent.org/programs/ahcccs-programs/differential-adjusted-payment-dap-programcye2023/
6. 2022 HIE P4P initiative for hospital participation in WISHIN. Wisconsin Statewide Health Information Network. Accessed December 15, 2021. https://www.wishin.org/ResourceCenter/P4PIncentive.aspx