How new patient data rules benefit payers


Starting next year payers may have new opportunities to collect real world data that was previously fragmented, incomplete and in some cases unavailable.

According to the rules going into effect January 1, 2021 by the U.S. Department of Health and Human Services, all federal insurers must share claims and other clinical data with patients through a secure third-party platform. Not only do these rules promote patient access and use of their own health information, but patients can grant permission for healthcare providers, payers and researchers to easily pull de-identified accurate and complete real world data to further advance medicine in new ways.

How enhanced access to real world data benefits payers

Real world data is most commonly based on patient records, which is at the center of what HHS plans to integrate and expand access to.

Payers use real world data, in part, to determine what drugs should or shouldn’t be covered and how much they should pay for them. Although randomized clinical trials provide the backbone for drug approval, real world data generated after a drug is approved, in a setting and patient population that is more realistic, provides great insight into the effectiveness of the drug. A study of 17 U.S. commercial health plans found that, on average, 51 of 307 cited clinical studies were based on real world evidence.

Real world data also supports outcomes-based contracts, which are payment models between pharmaceutical and insurance companies that are contingent on how the drug performs in their relevant population. For example, when Alnylam’s novel medication to treat an ultra-rare orphan disease was approved late last year, the CEO stated that participating insurance companies would only be liable to pay the full price for the medication ($575,000/yr.) if outcomes were similar to those seen in clinical trials.

One of the big barriers to applying outcomes-based contracts more broadly is difficulty collecting real-world performance data. The new HHS rules should facilitate access to this data.

Why access to real world data is not enough

It’s not enough to have access to real world data — you also need a team that can analyze the data to deliver value. AllazoHealth’s artificial intelligence engine has already learned from a comprehensive data set of over 12 million lives, including real world data from payer, provider and retail claims, social determinants of health, and patient interventions.

We use artificial intelligence to make a positive impact on individual patient adherence and gaps in care. We help payers and PBMs increase the effectiveness of patient engagement programs that focus on quality ratings.

New call-to-action