To share data with Medicare Advantage, Medicare must go further in interoperability

Interoperability, which the federal government has defined as “the ability of two or more systems to exchange and use information once it is received” – is essential to making our healthcare system more efficient and transparent for patients and consumers.

Imagine a system where pre-authorization is handled between payers and providers without delay to the patient or where a consumer can get information about the cost of a procedure or prescription and where to get it by pressing a smartphones. Similar transactions happen every day in many other industries, but for years we have struggled to consistently enable this portability of information in healthcare.

Although Medicare has spurred the evolution of data exchange, Medicare fee-for-service is currently not included in the critical area of ​​payer-to-payer data exchange. In an interoperable patient-centric world, it makes no sense for a national payer to cover some 38 million Americans be outside these exchanges. With Medicare Advantage (MA) plans covering a growing share of Medicare beneficiaries, half of Medicare beneficiaries are projected to be in MA’s plans maybe as early as 2023— Traditional health insurance urgently needs to implement a better way to exchange data with MA plans. As millions of beneficiaries see more choice than ever in their Medicare option, ensuring continuity of care will require portable clinical data.

Why It’s Important to Connect Medicare Fee-for-Service to Ongoing Interoperability Efforts

Thanks to the bipartisan 21st Century Cures Act, signed into law in December 2016 by President Barack Obama, interoperability has taken a big step forward. As part of implementing the legislation, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator of Health Informatics (ONC) built a new basis for the exchange of information using HL7® FHIR® Application Programming Interfaces (Apis). Former CMS Administrator Seema Verma Noted that new rules would break down “digital silos” by forcing “payers to step in and share this wealth of claims data directly with patients through a secure, standards-based API.”

verma prepare the terrain for a second phase of interoperability to share “patient claims, encounter data, and clinical data directly with provider EHRs,” to digitize pre-authorization, and to require some payers to use an FHIR API when customers change plans. Current CMS Administrator Chiquita Brooks-La-Sure has promised to fulfill “the purpose of allowing patients’ health data to follow them if they change health insurance plans”.

We agree with this approach: decision-makers must embrace interoperability as a way to improve the customer experience, not as another government mandate or “ticking a box”.

Just as payer-to-payer data exchange will soon be needed to help patients switching plans in other markets, we should expect the same between Medicare fee-for-service and PA. Beneficiaries of health insurance have the option of to change between Medicare fee-for-service and IA during certain enrollment periods, just as millions of Americans can switch plans during their employer’s open enrollment period. As Health Affairs articles (in 2015 and 2021) and other surveys found, plan switching occurs between fee-for-service and PA to varying degrees, and giving PA plans claim data to see a beneficiary’s history will not do than improving care.

For example, Cambia – where two of us (Dodge and Anderson) work and which administers MA plans in the Pacific Northwest – has seen approximately 5,500 new members join its MA plans from pay to Medicare act in 2022 but did not receive their claims history, information that could help ensure seamless continuity of care.

Interoperability is essential for safely and rapidly unlocking patient and consumer data across the healthcare system, leveraging it for better clinical decision-making. At a time individual plans‘ perspective and for the industry overall, interoperability will improve the situation of our Medicare beneficiaries live making care as smooth as possible. For example, if our PA plans had a history of claims for beneficiaries who transitioned from fee-for-service, they could streamline prior authorization approvals and prioritize members for drug review.

CMS paved the way for interoperability; He can do more

The federal government has developed several APIs to stimulate exchanges with the private sector. Chief among these initiatives is blue buttonwho began with the Department of Veterans Affairs in 2010 and after extended at CMS and the Department of Defense. In 2018, CMS took Blue Button one more step—a kind of Blue Button 2.0—by creating MyHealtheData at accelerate the development of health data exchange and consumer empowerment tools.

But Blue Button has its limitations for payer-to-payer exchanges. Blue Button is only available to the Medicare beneficiary, who must press the virtual button to retrieve their data and share it directly or authorize a app approved to share it. According statistics last updated in late 2021, just over 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 nation’s largest payer and share Medicare fee-for-service data that would help MA plans deliver care to beneficiaries. Such APIs already exist: the Beneficiary Claims Data API for responsible care organizations, the Point of Service Data API driver, and – perhaps most relevant – the AB2D API that allows stand-alone drug plans to receive fee-for-service health insurance data. AB2D Allows prescription drug plans (but not MA plans with prescription drug coverage) to access Medicare claims data for better drug management. A new API would essentially be an “AB2C” interface – in other words, sharing parts A and B of fee-for-service with part C – for MA plans so they can better understand the history of a beneficiary’s claims before proceeding with fee-for-service. -service. While AB2D was required under the Senate Finance Committee CHRONIC CARE Act, then included in the Bipartisan finance law 2018, it shouldn’t require an act of Congress to establish a new API. After all, apart from AB2D, CMS has released the vast majority of its API development tools under existing authority.

Interoperability 2.0 – Important marker for a new Medicare AB2C API

While the growing popularity of MA should be justification enough for a new API, the need for AB2C will be even greater once data exchange between payers becomes a reality in other contexts. In the first interoperability rule, finalized in 2020, CMS aimed to require payers to exchange data with other payers at the request of a patient. However, CMS now exercises discretion on this requirement, pending the development of additional rules. Director Brooks-LaSure Explain that this decision was based on the “operational challenges and risks to data quality in the absence of specific data exchange requirements and standards, in particular the absence of a requirement for an API based on standards”.

At the end of the last administration, CMS released what was often called a “Interoperability 2.0which would have added “several new provisions to increase data sharing and reduce the overall burden on payer, health care provider and patient through proposed enhancements to prior authorization practices.” But reviews felt that this settlement had been pushed through the process without sufficient comment. In addition, it only applied to qualified health plans in exchanges facilitated by the federal government and managed care organizations Medicaid and CHIP. It did not apply to MA plans in order to avoid being a major rule under the Congressional Review Act, to avoid a 60-day comment period.

The Biden Administration took of the final rule but does not back down from interoperability. In a 2021 blog post, Brooks-LaSure described the progress made so far, even during the pandemic, and highlighted efforts “to develop and finalize new rules regarding the exchange of information between payers.” Last March, the administrator gave an update to industry stakeholders that new interoperability regulations would be coming “soon”.

If CMS extends a proposed “Interoperability 2.0” rule to include MA plans, why not also announce the development of an AB2C API, to show the government’s commitment and interest in data exchange? One option would be to at least drive such an API in a regulatory sandbox similar to CMS’s Data at the Point of Care API. Better yet, why not align access to a new AB2C API with the emergence of the FHIR-compliant ONC Framework for Exchange of Trust and Common Agreement (TEFCA)? Making TEFCA the pathway for MA plans to access Medicare fee-for-service data would be a huge accelerator to overall TEFCA adoption.

The federal government continues to play a vital leadership role in the health care interoperability movement. Building on this leadership by releasing an AB2C API would not only give beneficiaries an easier way to share their Medicare fee-for-service history, but it would also accelerate the United States toward the long-standing data dream of interoperable healthcare.

Author’s Note

Kirk Anderson and David Dodge are employees of Cambia Health Solutions, which operates regional health plans, including Medicare Advantage plans, serving more than 3.2 million members in Oregon, Washington, Idaho and Utah.

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