Medicare Needs Increased Interoperability for MA Data Exchange

Medicare must go further to enhance interoperability and support data exchange with Medicare Advantage, according to a Health Affairs article.

While Medicare has driven the evolution of data exchange, Medicare fee-for-service is currently not included in payer-to-payer data exchange. With Medicare Advantage (MA) plans covering an increasing share of Medicare beneficiaries, traditional Medicare needs to build a better way to exchange data with MA plans.

Seema Verma, the former CMS administrator, noted that new 21st Century Cures Act rules would break down “digital silos” by requiring “payers to step up to the plate and share that wealth of claims data directly with patients” through HL7 FHIR application programming interfaces (APIs).

Verma set the stage for a second phase of interoperability to exchange “patient claims, encounter data, and clinical data directly to providers’ EHRs” and to require certain payers to use a FHIR API when customers change plans.

Chiquita Brooks-La-Sure, the current CMS administrator, has promised to fulfill the “goal of enabling patients’ health data to follow them if they switch health insurance plans.”

“Just as payer-to-payer data exchange will soon be required to support patients who switch plans in other markets, we should expect the same between Medicare fee-for-service and MA,” the Health Affairs authors wrote.

Surveys have found that plan switching occurs between fee-for-service and MA to varying degrees. Empowering MA plans with claims data to see a member’s history would help enhance care coordination, they added.

The authors noted that the federal government has developed several APIs to stimulate data exchange with the private sector. For instance, the Blue Button API began with the Department of Veterans Affairs (VA) in 2010 and later expanded to CMS and the Defense Department.

In 2018, CMS took Blue Button a step further by creating MyHealthEData to accelerate the development of health data exchange tools for consumer empowerment. However, Blue Button has its limitations for payer-to-payer exchanges, the authors explained.

“Blue Button is only available to the Medicare beneficiary, who must press the virtual button to pull down their data and either share it directly or authorize an approved app to share it,” they said. “According to statistics last updated at the end of 2021, a little more than a million beneficiaries—a fraction of those covered by Medicare—have done so.”

“To accelerate interoperable data exchange, CMS should recognize its vital role as the largest payer in the country and share Medicare fee-for-service data that would assist MA plans in providing care for beneficiaries,” the authors continued.

Such APIs currently exist, such as the Beneficiary Claims Data API for accountable care organizations, the Data at Point of Care API pilot, and the AB2D API. AB2D allows prescription drug plans to leverage Medicare claims data for medication management.

The authors suggested a new “AB2C” API that supports data exchange between Medicare fee-for-service Parts A and B to Part C could help MA plans better understand a beneficiary’s claims history before a switch from fee-for-service.

While the increasing popularity of MA should be enough reason for a new API, the need for AB2C will be even clearer once payer-to-payer data exchange becomes a reality in other settings.

In the first interoperability rule, finalized in 2020, CMS sought to require payers to share data with other payers at a patient’s request. However, CMS is now exercising enforcement discretion on that requirement, pending additional rulemaking, the authors said.

Administrator Brooks-LaSure explained that this decision was based on the “operational challenges and risks to data quality in the absence of specific data exchange requirements and standards, particularly the lack of a requirement for a standards-based API.”

At the end of the last administration, CMS published what was often referred to as an “Interoperability 2.0” regulation, which would have added “several new provisions to increase data sharing and reduce overall payer, healthcare provider, and patient burden through the proposed improvements to prior authorization practices.”

However, critics felt that this regulation was pushed through the process without adequate input. Additionally, it only applied to qualified health plans in federally facilitated exchanges and Medicaid and CHIP managed care organizations.

“It did not apply to MA plans so that it could avoid being a major rule under the Congressional Review Act, to avoid a 60-day comment period,” the authors explained.

The Biden administration withdrew the final rule but has been making progress on interoperability. In a 2021 blog post, Brooks-LaSure highlighted efforts “to develop and finalize new rulemaking regarding payer-to-payer information exchange.” This past March, the administrator gave an update to industry stakeholders that a new interoperability regulation would be coming “soon.”

The authors suggested that if CMS expands a proposed “Interoperability 2.0” rule to include MA plans, they should develop an AB2C API to show the government’s commitment to data exchange.

Further, CMS could align access to a new AB2C API with ONC’s emerging Trusted Exchange Framework and Common Agreement (TEFCA).

“Making TEFCA the path for MA plans to access Medicare fee-for-service data would be a huge accelerator to TEFCA adoption overall,” the authors noted.

“The federal government continues to play a critical leadership role in the interoperability movement in healthcare,” they continued. “Building upon that leadership by releasing an AB2C API would not only give beneficiaries an easier way to share their Medicare fee-for-service history, it would also further accelerate the US toward the long-held dream of interoperable health data.”