Initial deadlines are now fast approaching for the 21st Century Cures Act and the CMS Interoperability and Patient Access Final Rule—two legislative orders that, by establishing standard requirements around health data accessibility, transparency, and sharing, will turbocharge the decades-long push toward interoperability in healthcare.
Meeting these requirements has posed new challenges for healthcare payers, particularly in terms of the heavy lift required to clean, organize, and expose data for translation to FHIR standards. The regulations and deadlines themselves also presented something of a moving target in 2020, particularly due to the COVID-19 pandemic.
With that context in mind, it’s likely unsurprising that, in interviews with leaders from select organizations in late 2020, West Monroe found that simply meeting deadlines was the top priority, with about half taking a deadline-driven, sequenced approach. The primary concerns expressed at the time were around organizational readiness, with the majority expressing a limited sense of how new data sharing requirements would impact their end users, and none conveying overwhelming confidence in the state of overall operational readiness and training.
Today, with the deadlines firm and approaching, and the requirements augmented with tools and resources from CMS, health plans continue to be hard at work on planning, developing, and deploying new capabilities to achieve compliance with federal regulations and managing the organizational impact of those changes.
But the big question is: What’s next?
As we’ve detailed previously, simply “checking the box” to meet enforceable requirements in 2021 and early 2022 will be a significant missed opportunity to drive added value, both organizationally and across the larger healthcare landscape. We’ll take a deeper dive into this suggestion, outlining five ways payers might unlock value from interoperability requirements—and show why it’s important to begin that work now.
CMS-regulated payers have until January 1, 2022 to establish FHIR-based APIs for exchanging certain patient health information to help create a cumulative health record. Doing this meaningfully requires a mindset shift. Relinquishing the view that member data is a health plan’s intellectual property—and enabling a transparent and accessible portability—will shift the competitive advantage toward those plans that are most adept at surfacing, analyzing, and sharing data.
The pandemic has demonstrated just how significant a functioning payer-to-payer exchange can be in burden reduction for providers and patients. As a recent article in the Harvard Business Review put it, “even though up to 96% of hospitals and 86% of physician offices have adopted [electronic health records], we still don’t have EHRs that can rise to the information challenges that clinicians face every day, let alone those posed by COVID-19.” What’s more, data has become siloed and healthcare professionals in one setting have no way to access all the patient data captured by another.
Claims data offers the most comprehensive view of a patient’s health status, history, and socioeconomic conditions. While there is work yet to be done around how prior authorizations will be handled as part of interoperability mandates, it follows that standardizing the payer-to-payer exchange of member health information presents a momentous opportunity for payers to enhance value-based partnerships, improve the breadth and accessibility of patient data, positively impact patient and provider experience measures, and support more the efficient delivery of quality care.
Many organizations have so far been focused on standardizing and centralizing data for FHIR API connectivity. As this foundation is being constructed, future-looking payers should explore innovative technologies and strategies for scale—such as adaptable integration patterns and robust data architecture and governance, managing digital servicing and engagement assets, and advanced analytics.
Health plans should naturally be looking to leverage FHIR standards to make core processing adjustments that support effective data aggregation and the ongoing mapping of non-standard data. By design, of course, these practices will result in a higher volume of higher-quality data, which presents opportunities for improving data analytics and uncovering insights that were previously beyond reach.
Here, for instance, artificial neural networks and machine learning models can help illustrate population health trends and draw out critical insights. The information derived from the effective implementation of these new technologies can improve care management, delivery, and member experience.
It’s similar to what we’ve built at West Monroe, specifically for health plan organizations, leveraging our proprietary approach to Platform-as-a-Service (PaaS) along with Intellio™ DataOps.
New technologies could lead to increased data security, faster processing, and downstream cost reductions. But they must abide by CMS rules, including requirements that payers share USCDI data they maintain with patients through the Patient Access API and with other payers in the payer-to-payer data exchange.
Blockchain technology, which creates a new avenue of secure, “trustless” data exchange, might offer the key to the truly interoperable system desired by regulators—one which provides patients with a secure, single source of truth for their healthcare data, without putting the responsibility for it on the consumer.
This is not just a development play. It’s a chance to rethink the payer operating model and integrate tech and business capabilities around regulation-driven data exchanges as well as product development and portfolio operationalization. Becoming a blockchain solution provider is a concrete way health plans can transform around technology as a means to achieving greater operating efficiency and cost reduction, as well as laying the groundwork for new revenue streams.
Federal interoperability requirements emphasize data accessibility, quality, standardization, and sharing—all of which can open the door to more productive collaborations between payers, providers, and patients. This has direct implications for improving health outcomes and decreasing associated costs.
As such, these requirements create opportunities for innovative, collaborative, and forward-looking payer organizations to assert a competitive advantage in the delivery of value-based care.
Considering the oft-cited statistic that just 5% of patients account for nearly half of the nation’s total healthcare spending, it’s critical that clinical data be timely and complete. Access to such data in real time can lead to patient interventions and risk stratification strategies that reduce unnecessary utilizations and cut overall spending.
At the moment, however, claims data is often not comprehensive or timely enough to aid providers. For instance, they may receive data retroactively or find that it doesn’t reveal high-risk patients who might have medical and/or socioeconomic issues not listed in billing information.
HL7 FHIR-compliant APIs enable vendors to address these problems through innovative products that paint a fuller picture of individual patients. By leveraging these vendors, payers can utilize the timely and comprehensive data analytics they need to unlock the value of interoperability requirements.
Collaboration between payers, providers, and patients (and among providers themselves) is a critical component of value-based care. But today’s patients often play the middleman, bringing their health records to each doctor’s visit or requesting records for specialty providers—all of which is time consuming and can result in slower, lower-quality care (and poor patient experiences).
With effective interoperability standards in place, payers—who hold large data sets on their member populations—can play a more active part in helping providers paint a comprehensive picture of the patient journey, saving time and money for payers and providers alike while delivering better health outcomes.
Taking a proactive, future-oriented approach to interoperability regulations—and enabling richer access to consumer health data via a host of secure, self-service apps and digital tools—will help payers improve consumer experience and deliver on a value-based, patient-centric model of care that members are increasingly demanding from their health plans.
Developing a comprehensive, real-time view of members informs more nuanced and personalized engagement tactics. Payers will have to reach patients where they are through an omnichannel approach that ensures the right message is delivered to the right patient through the right medium at the right time. Similarly, better provider data management creates new opportunities to improve provider experiences across the network (i.e., better provider lifecycle management).
Behind all this, the payer-to-payer data exchange requirements present a golden opportunity for payers to see other payers as peers in the management and delivery of patient-centric care. Such an environment opens the door for innovation and market differentiation beyond traditional claims management, including extended care management, improved quality and experience measures (e.g., provider Net Promotor Score), and support of value-based arrangements.
With a consumer-driven healthcare landscape, patients can be more engaged and informed than ever before. This can have a direct impact on population health initiatives, which rely on patient trust within a given community, high-quality data, and open lines of communication between payers, providers, and patients. Ultimately, health payer organizations that take advantage of interoperability regulations in order to play leading roles in this virtuous circle will be at the forefront of the industry’s aims to produce better outcomes and new consumer benefits, from seamless authorization approvals to lower barriers between behavioral health, pharmacies, and care management.
The complexities of an organization’s custom-designed systems (e.g., EHRs for providers, or claims management platforms for payers) can lead to messy and expensive integration efforts. Interoperability can help support organizations in their acquisitive growth strategies.
With the move toward interoperability, payer organizations can acquire disjointed systems and apply a data integration layer, reducing overall costs and the time needed to complete integration efforts. Adherence to HL7 FHIR data standards will naturally help reduce the challenges of systems consolidation or transition, enabling quicker and more nimble growth opportunities.
Simply put, the door is wide open for innovative, forward-looking health plans that want to unlock the value of opportunities afforded by coming interoperability requirements. Now is the time to act, while the industry is in the midst of achieving compliance and attention to data sharing and portability and burden reduction is greater than ever.
These value opportunities provide some sense of the diversity of paths organizations can take through the movement toward interoperability as they shift from identifying potential value to realizing it – whether it be an established optimal analytics strategy or a streamlined, data-driven operation.
As these important legislative orders begin to go into effect, the payers who can see impending requirements not merely as compliance deadlines to be met but as opportunities to transform will be the ones who thrive for years to come.
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