New Marketplace

Promoting Interoperability: Roles for Commercial Payers

Article · May 9, 2019

Since the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009, health care has undergone a tremendous transformation in digitizing care. By 2016, more than 78% of doctors and 96% of hospitals were using certified health information technology (HIT). The field at large is now vibrant with opportunities seen in many other industries in an era of data and consumer revolution. This momentum is expanding to a broader set of health care industry stakeholders, all of whom are invested in achieving interoperability through a value-focused, patient-centered, and secure data sharing framework. A recent publication from the National Academy of Medicine entitled “Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care” makes a strong case for a more strategic and streamlined process for HIT acquisition as one under-leveraged opportunity to transform the field.

While many perceive interoperability as being driven mostly by technology vendors, providers, and regulatory bodies, public and commercial payers also play pivotal roles in shaping incentives and norms, therefore driving rules of competition in the marketplace. We view interoperability as a business imperative for enhancing value in health care, such as through value-based purchasing. Providers and payers must collaboratively meet the demands for data exchange within the ongoing transformation in health care. Nevertheless, public and commercial payers have a unique set of levers to shift the value proposition and expectations for data sharing, security, and compliance to standards. Payers may incentivize maturation and adoption of recognized standards, stimulate demand for interoperability through value-based contracts, and facilitate access and secure exchange of personal health data. In turn, payers also stand to benefit from greater efficiency in care quality improvement as well as population health management.

Federal Policy Impetus

The current federal policy landscape provides a synergistic backdrop for an industry-led push for a higher degree of interoperability. In particular, the 21st Century Cures Act (Cures Act), enacted in 2016, provides several opportunities to spark further advances in health IT interoperability. In late 2018, the Centers for Medicare and Medicaid Services (CMS) announced its intention to overhaul the Electronic Health Record Incentive Programs — now renamed the Promoting Interoperability Programs — by streamlining the Meaningful Use and Quality Payment Programs, with a focus on interoperability and reducing reporting burden. The Cures Act also includes penalties for information blocking and the establishment of the Trusted Exchange Framework and Common Agreement (TEFCA) as a vehicle to drive adoption of interoperability. TEFCA aims to provide a single “on-ramp” to nationwide interoperability while achieving a competitive and sustainable market.

Interoperability and Data Liquidity: Value Proposition for Payers

There are three main motivations for payers to actively foster health data interoperability. First is the quality, safety, and value of care. When clinical and administrative data can flow effortlessly, governmental and commercial payers can better monitor care quality and patient outcomes as well as value benchmarks such as reducing redundancy of services. Greater efficiency can also manifest through more standardized and timely reporting on key quality indicators from providers. Synchronizing reporting standards also allows for aggregation of data across entities and benchmarking performance. This is essential for payers who look to gain a competitive advantage in today’s value-driven health care landscape.

The second motivation is the pursuit of optimal population health and continuous learning. With the pressing need to better manage patients with multiple chronic conditions and social needs, payers should actively partner with providers to optimize care delivery coordination and promote the health and wellness of these patients.

To generate actionable insight, payers need a trusted data exchange framework to obtain clinical and claims data securely, as well as the ability to add on predictive analytic tools for population health management — for example, the capability to flag which patients are more likely to develop diabetes or progress in renal disease. Machine learning and artificial intelligence algorithms that proactively identify members at risk for an adverse event like a hospitalization, a readmission, or a fall — and thus need proactive intervention — are greatly enhanced with high-quality member attributes. Gathering this data, which mostly reside in silos across the nation’s data ecosystem, would be more efficient and provide better insight to providers and payers alike if it were all interoperable.

Thirdly, payers currently incur substantial operating costs from maintaining data exchange interfaces with a network of providers that are transmitting data through various record management systems, data formats, and interfaces. There is typically a high operating cost, for providers and payers alike, for executing prior authorization and utilization management tools. A movement toward a common data exchange platform can help to ensure care is appropriate and evidence-based with minimal operating costs by allowing modular add-ons for predictive analytic tools to aggregate and process multiple streams of data feeds, eliminating the costs of technology integration for many payers.

To date, commercial payers have demonstrated many use cases from leveraging interoperable data. Some illustrative examples are:

  • Integrating clinical data, such as biometric results, lab results, and drug-to-drug interactions, with administrative claims data, diagnoses and procedure codes, and provider demographics data to assess effective diagnoses, treatment plans, and medication adherence. As with several others, Blue Cross and Blue Shield of Louisiana applies artificial intelligence and machine learning methods to leverage clinical and administrative data to fine-tune treatment plans for members with chronic disease and identify those at risk for catastrophic events.
  • Integrating admission-discharge-transfer (ADT) reports with electronic health record data so that follow-up by primary care providers can be promptly scheduled for enhanced coordination of care for patients. One such example is the Chesapeake Regional Information System for our Patients (CRISP), a Washington, D.C.–based organization that provides ADT notification services across several states to health plans to inform their value-based care models.
  • Asynchronous coordination of a common treatment plan for each patient that will improve integrated care provided by different providers on the care team and improve outcomes-based care, reduce duplicate tests or contradictory treatments, and improve patient safety.

These use cases establish feasibility and demonstrate impact on clinical quality and value. They have also spurred vibrant innovations in the health IT marketplace. For example, several software companies such as FIGmd, Phreesia, and PatientPing are working with regional health information exchanges by leveraging various data sources to optimize chronic disease care management. Many payers seek new technical and business solutions to enhance risk prediction, improve return on investment, and, ultimately, provide seamless and person-centered care. Such frontiers are also characterized by the demand to look beyond traditional health care settings to manage health-related social needs and empower health-minded individuals and communities in the pursuit of improved well-being and a healthy lifestyle. AbleTo, BehaveCare, and Wider Circle are exemplary innovators in this area.

Three Payer Actions to Improve Interoperability

Most commercial payers already assert influence on data exchange requirements. For example, contractual agreements may include requirements for data sharing, file formats, field definitions, privacy, security, and the reporting time frame. At Blue Cross and Blue Shield of Louisiana, providers seeking to participate in its value-based payment program (Quality Blue Primary Care) are required to submit members’ clinical data in an Office of the National Coordinator for Health Information Technology (ONC)–recognized data format and in adherence to U.S. Department of Health and Human Services privacy standards. In addition to the traditional “flat-file” exchange with providers, Blue Cross and Blue Shield of Minnesota worked directly with electronic health record vendors to implement bidirectional data sharing with provider groups. The first generation of such data sharing streamlined the chart retrieval process and addressed access to information pertaining to the Healthcare Effectiveness Data and Information Set (HEDIS) and members’ clinical status. There have long been requirements related to provider audits to prevent fraud.

Working together, payers can further propel the adoption of critical technical and process standards, platforms, and certified technologies to incentivize system-wide interoperability. Augmented with value contracts, payers should collectively set the visions and guiding principles that, over time, shift the nature of competition toward innovation and quality in care delivery, rather than on data hoarding and proprietary practices. Such an approach would improve quality and reduce administrative costs for providers and payers.

We put forth the following three priorities for payers:

1. Incentivize maturation and adoption of recognized standards.

A fundamental requirement for meaningful interoperability is a common set of standards and data elements. Without these two requirements, entities cannot communicate. An enhanced level of uniformity in technical, syntactic, and semantic interoperability is the most basic requirement to exchange the information needed to inform critical decisions. A common model of data exchange that minimizes ambiguity and the need for manual transcription or file handling can enable more patient-centric workflow integration. This means more seamless care coordination based on a longitudinal patient care journey, as well as more comprehensive monitoring of population health, quality, and service utilization.

Working with their federal counterparts, commercial payers should endorse the adoption of a small set of best-in-class data exchange standards (e.g., ICD-10, JSON, or FHIR) and coalesce around priority data elements. Specifically, payers should support standards outlined by ONC’s Interoperability Standards Advisory and other recognized national public-private partnerships. Requiring the adoption of common, open-source standards also reduces the barrier to implementing additional analytic modules that optimize risk management. A consensus-based, transparent approach to security and privacy protection requirements will ensure all parties involved have the same clear expectations. For areas where industry standards are lacking — for example, measures for social determinants of health — public and commercial payers can facilitate the development and/or maturation of promising standards. Prior experience among insurers to agree upon a core set of key quality indicators taken by the Core Quality Measures Collaborative could provide valuable lessons.

2. Increase demand for interoperability through value-based contracts.

A lever unique to payers is the inclusion of language in the conditions for participation in value-based contracts, which can specify data sharing, interoperability, and privacy protection requirements. To ensure these levers are deployed effectively, payers should work with their network providers to identify priority areas where the lack of interoperability generates substantial variations in quality, costs, and outcomes.

Creating a shared view of risk transparency supports both contractual aligned incentives and the public good. These requirements provide guidelines for providers to hold their administrative staff and health IT vendors accountable for complying with these interoperability requirements, including establishing the reporting time frame. Payers can strategically embed incentives for adopting specific certified technology capable of sharing information, essentially lowering the cost of adoption for resource-constrained providers. Parallel to the establishment of penalties for information blocking proposed in the 21st Century Cures Act, payers might also consider reinforcing financial disincentives in the commercial space.

3. Facilitate access and secure exchange of personal health data.

Payers should elevate the priority of making sociodemographic, racial-ethnic, behavioral, and other social needs data interoperable — so that the care can be optimized for “point-of-life” across care settings and life stages, not just at points of care. Many payers are now seeking to incentivize the use of wearable, mobile technology, and telemedicine modules to include remote monitoring with standardized formatting and transmission of clinical data. Such information traditionally resides outside of care settings, and there are substantial technical and cultural barriers to integrate them. But as the technology becomes more mature and affordable, the business case becomes clear: One study by Fallon Health reported a savings of $687 per member per month by adopting remote monitoring system that allows seniors to safely live in their homes or subacute environments longer. While vibrant innovations are occurring in the technology sector from companies large and small, payers remain an important change agent in making these new advances viable.

Through value-based contracting or other strategic investment, payers can also accelerate the adoption of technology tools that engage and empower patients and families to make informed health care decisions and collaborate with providers in new ways. Payers can help in breaking down barriers that prevent patients from having electronic access and control over their own health records using the devices or applications of their choice. CMS has recently called for commercial payers to step up their efforts in sharing claims data and publishing application programming interfaces (APIs) to allow access.

We believe that now is the ideal time for payers to fuel the transformation of the health IT landscape toward one that is interoperable, patient centric, and value driven. Through collaborative alignment of incentives and expectations, there is an unprecedented opportunity to shape the nature of competition and innovation — away from one that has been stifled by data hoarding and proprietary interfaces. Payers have the responsibility to provide insight and guidance to ensure the advances in data liquidity and interoperability are not entirely driven by technology capabilities and workflow necessities — but by answering the right questions that matter to the lives we care for.

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