How TEFCA could drive payer-provider interoperability

The complexities of payer data exchange

While all three QHINs on the panel facilitate payer HIE to some degree, they emphasized that TEFCA is not yet operational for payer data exchange at scale.

"The use cases that we've been focused on are how to make it so that when someone delivers care, we can close the loop in as real time as possible with their insurance carrier," said Ryan Bohochik, vice president of value-based care at Epic. "When the insurance carrier knows about important details, we can get that back to the point of care, but TEFCA is not there yet."

Bohochik mentioned that payer-provider data exchange is complex because payers often work with third-party contractors. For instance, a health plan might partner with a vendor for care management or quality measure calculation.

"The waters get a little bit muddied because someone may be querying a health system for information about a patient or member, and from that health system's perspective, the person asking has no known relationship with this patient," Bohochik said. "In reality, they might be doing work on behalf of a payer. There just is this added layer of complexity when we get into the payment and operations-based world."

Catherine Bingman, vice president of interoperability adoption for eHealth Exchange, mentioned additional challenges to payer data exchange.

"I think that member attribution is crucial, and understanding that payers don't have the right to look at anything a patient has paid for themselves -- those things are so key," Bingman said. "You have to make sure it's right. That's why providers have been reticent to share data with payers. They have to, but they investigate it first before automatically sharing it, and that makes it painful, and it really has a huge impact on patients."

For instance, manual prior authorization processes often create delays in patient access to care. According to a 2023 AMA survey, 42% of doctors said their patients often see care access delays due to prior authorization, and 37% said they sometimes do.

"They have to get all that information, compile it, and fax it over," Bingham said. "It would really be great when we can identify the appropriate way to do it, and I think those SOPs are so crucial in this. The rules have to be in place."

Establishing use cases to promote trust

Matt Becker, vice president of interoperability at Kno2, noted that specific use cases and their respective requirements should be narrowed down to establish trust in payer data exchange via TEFCA.

"Payment and operations is a huge undertaking that can include HEDIS measures, quality assurance, and provider monitoring," Becker said. "There are so many different things in that use case, and all those are going to require certain things for that level of trust."

Bohochik echoed Becker, stressing that building valuable payment and operations use cases for TEFCA will be critical for adoption.

"I think there are a lot of opportunities here, but we can't try to solve everything," he said. "I am a big proponent of keeping a focused scope in mind, getting something where we can show successful outcomes, and then allowing the excitement and the community to build on it from there."

Additionally, while data standards are key for the technical aspect of interoperability, ensuring trust in data exchange is equally critical, Bohochik emphasized.

"You can build a network, but if no one feels comfortable using it, you may well have not done anything," he said. "If we can get to a place where every healthcare delivery system knows that if someone's requesting information under the use cases of payment operations, that they have a right to it, and we have those safeguards built in, that is what's going to move this to the point of scalability."

Hannah Nelson has been covering news related to health information technology and health data interoperability since 2020.