AHIP: 3 Factors to Consider for CMS Data Interoperability Rule

Reactions to the finalized interoperability rule have fallen predictably along industry lines, as payers and providers spurn the new rules but technology companies warm up to them.

For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.

There is some common ground, however, as Matt Eyles, president and chief executive officer of America’s Health Insurance Plans (AHIP), pointed out in a statement. He reiterated that AHIP embraces the same goals as CMS and ONC. The payer organization agrees that patients should be able to access their own healthcare data easily.

“Health insurance providers share HHS’s vision for expanded consumer data access and are committed to building a truly interoperable health care system that integrates and shares data seamlessly to enhance care coordination and improve outcomes,” Eyles said.

American Hospital Association, in a briefer statement, echoed this sentiment, noting that almost every health system has released information to patients digitally in some format.

However, Eyles added, patients have expressed two main priorities when it comes to personal healthcare data, citing an AHIP report on price transparency. 

First, patients want the information to be organized and personalized. Over 80 percent of adults prioritized conciseness over thoroughness when it came to receiving healthcare information.

Second, Eyles said, patients value privacy over access to data. Ninety percent of AHIP’s survey participants said that private technology companies and health payers should have the same data privacy standards.

There are three factors that healthcare policymakers and industry leaders must consider when forging a new rule related to interoperability.

Naturally, payers, policymakers, and healthcare experts must protect patients’ data privacy, which is the primary element that AHIP believes is lacking in the new interoperability rule.

Payers already have entire departments dedicated to fighting breaches of patients’ data privacy.

At Highmark Inc, a Blue Cross Blue Shield company, the fraud team is working to stay one step ahead of the scammers. It is an increasingly difficult task, according to Kurt Spears, the payer’s vice president of financial investigations and provider review.

In a recent interview, Spears described ever-evolving networks of scammers. The criminal activity that used to be executed by individuals and small groups has now adapted to involve well-funded, organized networks. 

Telemedicine and telehealth solutions, which CMS has been encouraging in response to the COVID-19 pandemic, often provide loopholes for scammers to gain access to information and data.

“The health plans are going to have to continue to come together more and work together even more closely,” Spears said. “We’re going to continue to have to be aligned on anti-fraud strategies and methodologies to have the biggest impact we can.”

Aside from protecting patients’ data privacy, payers and policymakers must focus their interoperability efforts on reducing healthcare spending, Eyles added.

Although Eyles did not explicitly point it out, this could be a problem for the finalized rule as well.

When the proposed interoperability rule came out in 2019, payers objected to the potential cost that CMS projected, offering a single estimate for what the rule would cost payers nationwide.

“Several commenters indicated concerns over what they believe would be a costly implementation,” CMS noted in the finalized rule. 

Commenters had various opinions about how to offset the cost burden. Some argued that payers should be allowed to pass the cost to patients and third-party partners, others argued that CMS should protect patients from bearing an increase in healthcare spending as a result of the rule, and still others suggested federal grant funding.

"We acknowledge that payers may pass these costs to patients via increased premiums. In this way, patients could absorb the cost of the API,” CMS replied. 

“However, we note the costs of ‘premiums’ for MA, Medicaid, and CHIP enrollees are primarily borne by the government, as are some premium costs for enrollees of QHP issuers on the FFEs who receive premium tax credits. We believe that the benefits created by the Patient Access API outweigh the costs to patients if payers choose to increase premiums as a result.”

CMS originally provided a cost of almost $800,000 per payer which it has now raised to an average of $1.5 million. The general range would extend from over $718,000 to $2.3 million.

ACA exchange premiums dropped four percent for 2020, Medicare Advantage premiums have been dropping, but Medicare premiums and deductibles are expected to rise, even before the interoperability rule was finalized.

Lastly, payers need to incorporate personalization into interoperability regulations.

Payers have been prioritizing personalization for patients and their employers even more in 2020.

At Blue Shield California, personalization is helping self-insured employers have more options for how they cover their employees.

Don Antonucci, senior vice president of commercial markets at Blue Shield California, told HealthPayerIntelligence that the variety of demands self-employers can have means that the ability to customize is key.

“We've got to have a system and solutions that are high-tech and high-touch with this personalized approach,” Antonucci said.

The payer partnered with a third-party technology vendor to offer a greater selection of benefits and benefits navigation assistance for self-insured employers and their employees, in the hopes of cost reductions and better member engagement.

“With this capability we expect that members are going to be able to understand their benefits really clearly. We expect that we're also going to be able to see higher quality, lower costs as a result of this type of a combination for the right large self-funded employers,” Antonucci added.

While many affirm the need for interoperability, the healthcare industry as a whole has only been crawling in that direction. In an Accenture report in October 2019, 17 percent of healthcare executives admitted that they were “completely unaware” of the regulation’s demands. 

However, 26 percent of payer executives surveyed said that they are “very prepared” for the new interoperability rules.