Why Interoperability Rule Could Spur Payer Innovation

The Interoperability and Patient Access rule presents an array of challenges for payers, but it may also pave the way toward new improvements.

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access final rule aims to provide patients with improved access to their health information. To get there, the mandate requires payers to share certain data with patients, providers, and other payers. The requirements extend to Medicare Advantage, Medicaid, Children’s Health Insurance Program, and Qualified Health Plan issuers on the Federally-facilitated Exchanges. Although the compliance deadline was extended to July 1 of 2021 because of the COVID-19 pandemic, there are both immediate and long-term challenges involved for payers. Despite these difficulties, some have highlighted the opportunities to innovate and prepare for the future of health care.

Short and Long-Term Challenges for Payers

Because payers have been required to implement patient access rules in a time-bound manner, it poses a hefty challenge in terms of “cleansing, aggregating, consolidating, and converting data” into a Fast Healthcare Interoperability Resources (FHIR) compliant format, explained Shreesh Tiwari, principal, and digital & technology leader for Health Plan & Provider Practice at ZS Associates. “This is a significant undertaking in a short period of time.”

The rule requires payers to provide access for health care data-sharing through open application programming interfaces (APIs) so that the information can be used by the third-party applications utilized by patients, explained Marty Mattei, PharmD, chief clinical officer at managed care health tech company Managed Markets Insight & Technology (MMIT). This presents an array of both short and long-term challenges for payers.

According to Dr Mattei, payers will need to correctly interpret the final rules to implement solutions and determining what the base requirements are remains a pain point. The identification of appropriate solutions for the ingestion and transformation of data endpoints for APIs is another challenge.

He also highlighted the internal resource constraints—such as IT, administrative, and clinical—for payers to implement according to HIPAA and HL7 FHIR guidelines as well as the ongoing maintenance and support needed to meet CMS requirements considering they will evolve and require ongoing oversight on the part of payers.

“Although CMS is exercising enforcement discretion for parts of the final rule, the biggest short-term challenge will be the technological lift required to meet the various requirements of the rule,” said Ryan Atwood, MBA, vice president of payer relations and regulatory compliance at Engooden Health, a chronic care management platform. “This challenge will persist as the payer-to-payer exchange rules are finalized, and payers will also have the added challenge of managing access to APIs from third parties.”

Beyond that, he added, payers will be faced with millions of consumers—and employers—who want to access this information but do not fall under the plan types specified within the rule.

“Although the Interoperability and Patient Access Final Rule has tremendous potential to transform the way the health care ecosystem accesses and shares data, it also comes with numerous challenges,” said Jonas Shoor, MBA, Director of Interoperability Product Management at Gainwell Technologies.

In the short-term, payers must act quickly to meet the new requirements, including data transformation, provider directory implementation, and FHIR based API service development. “Long-term, he added, payers will need to continue building and maintaining the technical infrastructure that’s required to support these complex data sharing needs as the situation evolves.”

When he considers the various challenges presented by the new mandate, Craig Wigginton, Chief Technology Officer at health care tech company Icario, highlighted Patient Access APIs as a significant one. “The interoperability rule requires payers to make paid claims available to members within a short time frame from adjudication of the claim, which is presenting new challenges for payers,” he said. “The velocity of data sharing is requiring payers to rethink some of their systems and processes with a new perspective.”

Another difficulty pertains to Provider Directory APIs, considering greater access to formulary coverage and provider directory information will likely “stretch health plans.” Mr Wigginton highlighted an undertaking by the Council for Affordable Quality Healthcare (CAQH) called the CAQH Endpoint Directory, which publishes validated FHIR endpoints, but added that “With 300,000 possible connections, and without a trusted directory, each plan and developer would have to find, catalogue, verify and maintain these endpoint connections on their own.”

Will the Rule Impact Different Sized Payers Differently?

Each payer is unique, of course, but some say size could play an important role in terms of how payers are impacted by the Interoperability and Patient Access final rule and in terms of how they respond to its requirements.

Large and small organizations will likely be affected differently, according to Mr Atwood, especially in terms of the cost implications of the technological lift involved. “But because these costs can likely be included as part of quality improvement for MLR calculations, it may mitigate some imbalance,” he said. Smaller, more agile plans might also be able to adapt to changes more quickly, which could offer an advantage in some markets.

Small to mid-size payers facing internal resource challenges will likely turn to vendors for turnkey solutions to achieve compliance with CMS requirements, Dr Mattei said. Larger payers, on the other hand, could wind up using a mixture of off-the-shelf vendor solutions and internal development.

New Rule Presents New Opportunities

Some industry experts have pointed out that payer organizations viewing the mandate as a compliance issue and nothing more could be missing out on an opportunity to go beyond the bare minimum to set themselves up for the future of health care.

The CMS Interoperability Rule isn’t just a compliance issue, according to Mr Tiwari. Instead, it presents an opportunity for health plan leaders to create value for their members and organizations. He believes payers ought to see the mandate as a strategic opportunity to gain a competitive advantage.

“There’s a tremendous opportunity to innovate,” said Mr Atwood. Payers have limited insight into their members’ non-clinical health factors, like physical or social environment, which can significantly impact overall health. “The interoperability ruling gives payers an opportunity to integrate with companies and technologies that provide additional, detailed insight into members’ health factors and combine that data with periodic member data to gain a more comprehensive understanding of their membership,” he added.

Mr Shoor believes this type of data sharing within the health care landscape will “revolutionize data analytics capabilities at all levels” and help drive significant innovation—both organizational and governmental. “The mandates mark the most extensive healthcare data sharing policies the federal government has implemented to date, requiring public and private entities to share health information safely and securely between patients and other parties,” he said.

In the context of an ongoing global pandemic, he added, payer and public health agencies could harness data sharing for the sake of disease surveillance and vaccine monitoring. And these efforts can contribute toward strengthening payer performance and supporting population health.

The rule could certainly help spark new payer innovation, according to Mr Wigginton. “Interoperability is forcing payers through digital transformation, especially as it relates to data availability and velocity of data processing,” he said. Requirements related to cost, network transparency, and address standardization mean major changes are anticipated.

For members, the whole concept of requesting medical records and waiting for a claim to come in will eventually become obsolete. At the same time, however, data governance around all these issues is lagging. It ought to be both nationwide and uniform, he added, so there is still plenty of work to be done moving forward.

According to Dr Mattei, innovation from payers will probably come in the form of greater levels of transparency for patients and providers as information becomes more readily available to them. “This is something that has been lacking in the past and provides an opportunity to break down the existing silos between patients, providers, and payers,” he said. This could, in turn, lead to a more engaged patient population and allow a more consumer-centric model of care to evolve over time.