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Health Plan Data Exchange May Be Closer Than We Think

Originally Published On: January 25th, 2023

Susan Bellile’s blog, published last year, dives into the importance of enhanced interoperability. She discusses how the now-finalized CMS Interoperability and Prior Authorization Rule (CMS-0057-F), released on January 17, 2024, will affect health plans, payers, providers, and members. Explore her insights to gain a comprehensive understanding of the implications for these stakeholders.

Having worked with healthcare data for most of my career, supporting both provider and payer organizations, it’s now clear to me that when it comes to clinical data, providers have more depth of information while payers have more breadth.

Simply put, the record at my primary care provider’s (PCP) office has clinical detail from my examinations, laboratory tests, immunizations, and even questions I might have posed through a patient portal. But my health plan, using information gathered primarily through claims, knows that I consulted a specialist two years ago, that I did or didn’t fill my prescriptions, or that I may have visited an emergency room in another state. As the patient, I access my information using multiple patient portals because my primary care provider and my specialist don’t use the same electronic health record (EHR). I also access information from my health plan through their member portal.

Giving patients the ability to download data from different portals into a smartphone application was the vision behind the Patient Access API, one of the interoperability rules that went into effect in July 2021. Sounds appealing, but health plans have seen a low volume of downloads from their Patient Access APIs, suggesting that only a minority of consumers are doing that today.

In a previously published blog, I discussed the limited adoption of the Patient Access API and expressed hope that the payer-to-payer data exchange rule, whose enforcement was paused in September 2021, would help by consolidating a member’s healthcare history when they switch health plans. The Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule that was just released in December 2022 further advances meaningful sharing of member data maintained by payers. The proposed rule:

  • Adds prior authorization status to the information the health plan must make available to a member, the member’s provider, and the member’s new health plan. A view of services requested, approved, or denied helps build that comprehensive picture of a member’s recent interactions with the healthcare system.
  • Creates a requirement to make the health plan’s information about a member available to the member’s PCP. I’m betting that a lot of members would prefer to have their health plan manage that exchange, rather than having to obtain the information themselves and deliver it to their PCP.
  • Clarifies the standards and processes for a member’s new plan to obtain historical information from the member’s prior plan. Because health plans have not previously shared information with other health plans, (who may be competitors), it is important to establish some rules of the road.

These are all important steps toward easier exchange of the payer’s more comprehensive view of a member’s healthcare history. However, these new ways of sharing information put an additional burden on payers, where data on one member is typically acquired from multiple sources and stored in many disparate, internal systems. Creating a single, comprehensive, and coherent view of each member’s data – to be made accessible via Fast Healthcare Interoperability Resources® (FHIR) APIs – is the biggest challenge to meeting these new proposed rules. 

While the FHIR standard facilitates healthcare data exchange between different systems, it does not address the underlying data quality. If the source data is incomplete and inaccurate, the compiled record will be as well. 

So why am I still optimistic that we will make progress? Diameter Health, now part of Availity, has the expertise required to meet this challenge with Data UpcyclingTM –a five-step process that includes normalizing, enriching, reorganizing, deduplicating, and summarizing raw clinical data to turn it into a standards-based, interoperable asset. Availity looks forward to continuing this interoperability journey with our payer and provider partners.

If you are interested in learning more about upcycling technology, download “Why FHIR is Not the Holy Grail of Data Interoperability” Insight Brief.