John D’Amore

What health plans can do today to prepare for the new patient access and interoperability rules

September 15, 2020
By John D’Amore

Although the COVID-19 pandemic led the federal government to delay enforcement of new patient access and interoperability rules, that doesn’t mean health insurers should lose focus on these important and groundbreaking regulations.

These two “transformative” rules – one from the Office of the National Coordinator for Health Information Technology (ONC) and the other from the Centers for Medicare & Medicaid Services (CMS) – are intended to “put patients first” by giving patients safe and secure access to their own health data, according to the U.S. Department of Health and Human Services (HHS).

A key objective of both rules is to provide patients and members the ability to use third-party apps on their smartphones, effectively letting them exercise the same control over their health data as they do over financial, retail, and other consumer transactions. The CMS rule holds payers who offer Medicare Advantage and Managed Medicaid plans accountable for sharing “claims and other health information with patients in a safe, secure, understandable, and user-friendly electronic format through the Patient Access application programming interface (API).” Additionally, the ONC rule requires the provision of clinical data using the new standard for data access called Fast Healthcare Interoperability Resources (FHIR) Version 4.

For health plans, which have the most urgent deadlines, there is no time to waste. Now is the time for action.

Know your deadlines
As it stands today, the first step related to the new rules that health plans should take is to mark their calendars for near-term deadlines. While some industry observers previously expected these deadlines to be a few years out, HHS had other ideas, initially establishing an aggressive target of Jan. 1, 2021, for payer compliance. As a result of the pandemic, enforcement of payer compliance has been pushed back to July 1, 2021, but the following deadlines still need to be top-of-mind for payers.

July 1, 2021
• Patient Access API: Payers must provide members with access to their claims and clinical data using new API standards.
• Provider Directory API: Payers must provide public-facing directory services for provider networks and drug formularies.

January 1, 2022
• Payer-to-Payer Data Exchange: Payers must make data available through APIs to other payers as members change plans.

Early-to-Mid 2022
• Improving the Dual Eligible Experience: Additional data sharing requirements will enable better coordination for members covered under both Medicare and Medicaid.

Ready, Aim, FHIR
Aside from remaining focused on the above key deadlines, the next most important priority for payers today is to develop plans implementing data-access capabilities via FHIR R4. Though most health plans currently maintain online portals for members, the requirement to provide APIs for members to access data through apps on their phone will likely create challenges for many payers. Importantly, the regulation stipulates that payers will not be able to deliver solutions where only some apps can be used.

Instead, the rule explicitly states that the Patient Access API must include all the required clinical information that payers maintain for each member with a date of service on or after January 1, 2016.

Adding to the complexity is that some parts of FHIR R4 became normative standards in early 2019, meaning that they are ready for widespread use. Other parts, however, are less mature but will still need to be used by payers.

Five categories of data
Health plans must leverage the FHIR standard to make the following five types of data available: 1) adjudicated claims; 2) encounters with capitated providers; 3) provider remittances; 4) enrollee cost-sharing; and 5) clinical data, including laboratory results.
Most health plans already have systems to provide the first four types of data, which can be mapped to three parts of FHIR, specifically: explanation of benefits; patient; and coverage resources. However, few health plans are well versed with FHIR and many do not yet make data available by API. Many payers have begun investing time and resources into the significant effort required to make this data available. For payers that have yet to begin, there is no time like the present.

Clinical data, the fifth of the above categories, represents the most valuable type of data for patients, but unfortunately also presents the highest hurdle for many plans with less experience managing clinical data. That is because the success of FHIR as an exchange format is dependent on the data being well-structured. However, raw patient data is often incomplete, redundant, or inconsistently coded, and as a result, its value for patient access via FHIR is limited.

For example, information that is poorly formed in the source electronic health record will render incomplete as a FHIR resource. More than just delivering data in the correct FHIR format, payers need a solution that normalizes and enriches raw clinical data so that information presented to the member is complete and useful.

For many payers, the ability to properly normalize and enrich data is likely to hold the key as to whether their efforts aimed at member data-sharing are met with success or failure. While payers may be able to meet the CMS requirement of delivering member data if the data isn’t usable or worse – if it’s incorrect – the result could be reduced member satisfaction scores and HEDIS scores. Nonetheless, the federal government’s efforts to improve patients’ access to their own health information are long overdue and well worth the effort. Payers that get moving quickly on plans to obtain compliance with these measures are likely to be rewarded with greater member satisfaction and loyalty.

About the author: John D’Amore is the president and co-founder of Diameter Health, a clinical data optimization company focused on improving the quality and quantity of actionable health data.