Rhapsody Health Solutions Team

What payers need to know about integrating clinical data

Here it is again. A once in a lifetime (or twice, if you were around for the switch to value-based) chance to reposition your organization in the competitive payer market and come out on top.

The new rules set by CMS and ONC in March 2020 mean major changes for how and what health data is shared.

The intention behind the new rules is to provide patients better access to their medical data, with the hope that a more informed patient can more effectively manage their health needs. Boom! Clinical quality outcomes rise, the payers and health systems save money, everyone wins. However, the steps to enable that end state effectively require all health participants to adopt FHIR APIs.

This means a near industry-wide standardization that makes data exchange possible on a massive scale. With these changes comes the opportunity for new ideas to shift and redefine the way we all create value in the healthcare ecosystem.

How will your organization respond?

In a recent edition of the Verinovum New Truths Educational Series, How payers can leverage data pipelines for five-star results, industry leaders explained what the new CMS rules could mean for payers.

Panelists Drew Ivan, Chief Product and Strategy Officer at Rhapsody, and Mike Noshay, Founder and Chief Strategy Officer for Verinovum, described the technical challenges posed by the mandate and shared their perspectives on how payers can leverage the changing data landscape to get ahead.

Better data means a healthier ecosystem

The move to comply with the CMS rules effectively means payers will be able to create a comprehensive patient record that includes diagnoses, labs, results, etc. They can use this data to understand and serve their members in all-new ways, including:

  • Developing new payment models
  • Improving risk-based assessments
  • Proposing risk-sharing strategies

The increased availability of patient data will also help health plans improve the accuracy of their quality measures, which can lead to better outcomes and better reimbursements.

Case in point, Mike Noshay shared a story about how one payer leveraged clinical content to better understand comorbid disease states and used that analysis to identify potential patients and provide care management modules three to six months sooner than they otherwise would have. The company found that this approach saved more than $250 per patient per month.

While driving up reimbursement rates is important for the bottom line, “the real goal should be to change the game entirely and use that data to drive new capabilities around case management, predictive analytics, population health management so that we can make a positive impact on members’ lives,” said Drew Ivan, which these new rules make possible.

Wait, don’t payers already get patient data?

If you’re asking, “don’t payers already get a lot of data about patients?” The answer is yes—but maybe not the way you think.

Payers do receive patient data today, however, the current technology makes transmitting data and combining different data formats challenging, costly, and time-consuming. Both data transmission and data formatting challenges result in lagging or reactive analysis that’s treated as historical reporting versus real-time insights. Ensuring this data is real-time, actionable, correctly attributed, and comprehensive are key indicators to ensure your organization will actually benefit from your solution spend in support of these new payer interoperability rules.

Data transmission presents a problem because it only happens one of two ways depending on the data archetypes. The provider can either send one patient file at a time or all their patients’ files together. Of course, one at a time is too slow, and using the floodgate approach is too fast and could violate HIPAA guidelines (in the likely event the payer does not cover all the providers’ patients).

With data formats, there are so many different types of data that combining data from different systems and sources for analysis becomes a very complex process—and explorative analysis to respond to new ideas or market changes is nearly impossible.

Making data part of the answer

As a whole, the industry is moving toward adopting the HL7 data standard and the new rules from CMS and ONC that encourage use of FHIR APIs. Together these capabilities may help payers use clinical content in a more real-time fashion to gain a comprehensive picture of a patient and evolve their business lines to help with care intervention and overall outcomes.

It’s no secret that the move to FHIR APIs will be a lot of work for payers as well as providers. However, when the dust finally settles (or more likely, when the first payer breaks ahead of the pack), we’re bound to see all-new standards of care driven by powerful healthcare interoperability solutions.

If you’re wondering how you can use FHIR APIs to help you reimagine clinical data exchange, let’s connect!

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