Interoperability. All of a sudden the word is everywhere! Is it just the latest in a long line of trendy health-industry buzzwords? Or, in the midst of handling the COVID-19 pandemic, is this another critical challenge health plans need to attend to?
Whether or not anyone is ready for another 2020 challenge; It is officially the latter. The CMS Interoperability and Patient final rule is the focus of a new mandate from the Centers for Medicare and Medicaid (CMS) and ready or not — it marks a new chapter for healthcare payers.
What is Interoperability?
Interoperability, formally defined, is the ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of healthcare for individuals and communities. Essentially, it means that different sources and different types of data, from different types of organizations, must be stored and transmitted using common language so that it can be shared, combined, and easily accessed — while also meeting privacy and security standards.
What is the CMS Interoperability and Patient Access final rule?
The CMS Interoperability and Patient Access final rule complements the Cures Act Final Rule (also known as the Interoperability and Information Blocking rule), which mandates that the healthcare industry adopt standardized application programming interfaces (APIs) to allow individuals to securely and easily access their data when they need it most and in a way they can best use it. This member-centric move means the payers must be able to facilitate the exchange of comprehensive claims and clinical data between their members, member-selected, third-party software applications, and competing payers. It represents a culmination of more than 20 years of interoperability policy to be put into action – quickly. The rule consists of four policies; and payers have no time to spare in becoming familiar with the intricacies of each.
How does it serve members?
Today, people can easily manage finances, travels, and shopping carts online — but still spend countless and frustrating hours on calls trying to accomplish basic healthcare tasks, like access their own health records, or share their health histories with a new provider. The final rule means this is no longer acceptable. Instead, members must be able to securely access health data through their mobile devices, at no additional cost, just as they can across other industries. In addition to saving member time and hassle, this serves members with direct health benefits. By being able to access their healthcare data at any given time and through any device, members can become experts in their own health and wellbeing needs. While there is no doubt that the new rule will have a significant and positive impact on patient care, the question that remains is, are payers ready?
What does it mean for payers?
Currently, all the information that describes a member — clinical, claims, various touchpoints, day-to-day interactions, etc. — are collected and tracked in disparate systems that don’t speak to each other, such as EHRs, EMRs, payer systems, ehealth apps, portals, wearables, and more. While not all payers are subject to this final rule, the new interoperability mandate marks a forward shift to member-centricity that is changing the face of the healthcare industry. With rapid changes required for government-sponsored plans, it represents a critical call to action for the entire industry. The new rule means payers must adopt foundational standards that support data exchange via secure APIs, and implement new best practices for sharing, receiving, and leveraging secured patient data — all while facing tight implementation timelines and vague interpretations of requirements.
For most payers, the new rule is undeniably daunting. However, per design, it accelerates innovation and paves the way for health plans to create better member experiences, improved health outcomes, and reduced costs.
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It represents a historical moment of opportunity, creating huge business advantages to those plans who act quickly and wisely to meet the new standards. For payers, whose business goals revolve around understanding members, collecting and aggregating 360-degree member data offers the greatest potential for better health outcomes.
When member data — from claims to digital engagement to ehealth app data — is connected and coordinated, it enables true member-centricity, improving health outcomes, increasing member satisfaction, and reducing the overall costs of healthcare.
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So, what’s next?
Practical advice for any health plan is to:
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