Health Plans Intelligent Care Management Technologies. EHR Integration. Value-based payment programs. HELIOS. Closing the Loop.

5 Reasons Why Health Plans Must Adopt Intelligent Care Management Technologies

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Over the last 10+ years, nearly all health systems and healthcare providers have adopted some sort of electronic health record system (EHR). And since the start of the pandemic, these care providers have accelerated the use of telemedicine and remote patient monitoring tools to support their care management services. In addition, healthcare consumers are increasing their use of apps to manage their health, well-being, and related spending. These technology-based developments have enabled the collection of patient, clinical, and financial data in types and volumes never before possible; data that is essential to the operation of value-based payment programs.

Health Plans as ‘Keepers of the Data’ Need Advanced Care Management Capabilities

Moreover, recent regulations on data transparency, interoperability, and patients’ access to their data are strengthening health plans as a central repository of longitudinal aggregated data for plan members. By leveraging that data with technologies like artificial intelligence, machine learning, and robotic process automation, health plans are able to assist their provider networks with identifying, delivering, and closing the loop on the preventative, ‘whole-person’ and other population health management services critical to value-based programs.

RELATED:Intelligent Care Management Technology: Driving Alignment Towards The Quadruple Aim – Webinar, Thursday, October 7th, 2021 at 3:00 PM ET

Intelligent Care Management – Exceeding Typical Health Plan Capabilities

Intelligent Care Management Technologies (ICMT) go beyond the often disjointed utilization management, case management, and other clinically-focused services historically performed by health plans and provides an integrated, holistic approach to care.

Here are five reasons why health plans should be adopting Intelligent Care Management Technologies:

  1. Improves Patient Outcomes by Facilitating a Whole-Person Approach to Care

Being able to integrate, interpret, and efficiently utilize large data sets that span an individual’s entire health profile allows plans to help their provider network deliver insight and care at the right time and place. Potential life-threatening issues and medical complications can be caught sooner, enabling care providers to improve patient outcomes with fewer resources and at a lower cost.

  1. Extends Value of Provider Systems and Resources

Beyond not having a more complete patient profile, many care providers lack advanced analytics, guidelines, and tools that plans are better equipped to provide. The intelligent care management technologies shared by a health plan can positively impact provider practice patterns and improve overall care delivery to their patients and the plan’s members.

  1. Reduces Burden and Expense of Provider Network Partners

ICMT is integrated with existing provider and plan workflows with context, priority, and transparency to support faster and more informed care decisions by network physicians, nurses, and other care provider resources. Supporting clinicians helps to reduce the burden of increasing patient volumes and contributes to achieving the Quadruple Aim.

  1. Helps Address Social Determinants of Health and Leverages Community-Based ResourcesHealth Plans Intelligent Care Management Technologies. EHR Integration. Value-based payment programs. HELIOS. Closing the Loop.

ICMT helps tailor care based on social determinants of health, assessment tools, and guidelines to help identify, coordinate, and close the loop on services provided by network providers and local community-based organizations. Closing care gaps and assisting members and patients with obtaining medical and non-medical services from local organizations is an important part of value-based payment programs.

  1. Enables Health Plans to Assist Network Providers with Taking on More Risk

As care provider organizations and payers enter into more value-based care arrangements, it is critical for those organizations to strategically take on more risk and equitably share the cost of providing that care. Money spent on reactive care, avoidable hospital readmissions, and services performed in costly settings – among other things – are not only a waste of money but also burden increasingly scarce provider resources and negatively impact the patient experience. Intelligent Care Management Technologies allow plans to support their provider network by identifying, helping to coordinate and close the loop on proactive care across the care continuum.

RELATED: Intelligent Care Management Technologies: Key Considerations & Opportunities

Spreading Intelligence to Traditional Care Management

As the transition from fee-for-service to value-based payment programs accelerates and employers and consumers demand more their healthcare dollars, payers and providers must work with each other in more collaborative, intertwined ways. Utilizing intelligent care management technologies enables and supports the payer-provider collaboration essential to operating in today’s healthcare environment; and value-based arrangements in particular.

To learn more from healthcare leaders intimately involved with implementing and operating intelligent care management technologies, join us on Thursday, October 7th, 2021 at 3:00 PM ET for our live webinar “Intelligent Care Management Technology: Driving Alignment Towards The Quadruple Aim” presented by VirtualHealth.Health Plans Intelligent Care Management Technologies. EHR Integration. Value-based payment programs. HELIOSIf you’re not available, register anyway and we’ll send you a recording including presentation materials after the event.

Payment Integrity. Fair and Equitable, Structurally Sound Payment System. Healthcare. payment reform. provider payment models. Value-based care.

Payment Integrity’s Role in Building a Fair & Equitable, Structurally Sound Payment System

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Each year over the last decade, ‘Healthcare Payment’ and ‘Data & Analytics’ have been on the HCEG Top 10 list of challenges, issues, and opportunities facing healthcare leaders; whether payment reform, big data and advanced analytics, payment integrity, or as in the case of the most current 2021 HCEG Top 10+ list: ‘Data & Analytics with respect to Costs.’ And now, the pandemic’s impact on healthcare provider revenue, the increasing financial responsibility of individuals for high and widely priced healthcare services, and multiple price transparency regulations such as the No Surprises Act and Transparency in Coverage are forcing stakeholders across the industry to address fundamental structural issues surrounding healthcare payments and provider reimbursement.

On Thursday, September 9th, the first in a series of Focus Area Roundtables on Payment Integrity and ‘Data & Analytics with respect to Costs’ took place with HCEG’s executive director Ferris Taylor joined by Kurt Fullmer and Andrew Cone, two healthcare industry leaders with MultiPlan – HCEG’s Focus Area Partner for ‘Data & Analytics with respect to Costs’. Seventeen other leaders from health plans, health systems, provider organizations including IPA’s, and industry consultants joined the roundtable discussion focused on the following topics:

1-How providers and payors – and plan members and patients – can find common ground in terms of payment and reimbursement
2-The ways the No Surprises Act may change the future of provider networks and reimbursement
3-How payment integrity must evolve to be considered by providers as fair and equitable

RELATED: Trends that are re-shaping payment integrity strategies

Finding Common Ground Among Payers, Providers, Plan Members, & Patients

Ferris kicked off the roundtable by asking how healthcare stakeholders could find common ground in terms of reimbursement. MultiPlan’s Andrew Cone noted the importance of keeping in mind the wide degree of variance that exists in the healthcare market across product types such as Medicare, Medicaid, Commercial, Group, Individual, etc. There’s a clear benefit to payers and providers to adopt consistent patient attribution approaches, quality measurement, and risk adjustment practices across all product types.

He also called out the way in which healthcare services are priced relative to other major products like buying an automobile and acknowledged that some controversial issues, gamesmanship, and outright bad behavior by some stakeholders have driven regulations like the No Surprises Act and that the next few years will be “very interesting” in terms of establishing common ground between healthcare’s stakeholders.

Listen here to Andrew Cone share context for establishing common ground among stakeholders. [11:32 – 13:31]Finding Common Ground Among Payers, Providers, Plan Members, & Patients

Value-based Care Programs Support Common Ground

One participant, a leader of a physician organization, shared her perspective that reducing or eliminating ongoing and often arbitrary changes to provider payments by payers and moving to more fixed, regular payments found in value-based payment programs would go a long way toward establishing common ground among healthcare stakeholders and reduce or eliminate the gamesmanship sometimes played.

It was noted the larger impact and ongoing challenge related to regional differences in care patterns and related reimbursement rates. And the challenges associated with defining levels of care at expected levels and consistently delivering those care at agreed-upon levels.

Listen here for additional impacts on establishing common ground. [19:25- 20:11]

New and Increasing Administrative Burdens Impact Costs and Payment Integrity

One participant shared their experience with increased costs associated with providing preventative care to patient populations vs. reactive care to a subset of a patient population. Others in the roundtable noted increased – and new costs – associated with identifying individuals in need of preventative services, capturing and reporting value-based measures, and identifying and accessing correct plan and community-based resources on behalf of their patients.

RELATED: Surprise Billing and the Impact for Payors

The Right Information at the Right TimeThe Right Information at the Right Time

Increased levels of provider interaction with plans on behalf of their patient population were identified as a recurring cost driver. One health system leader both praised and bemoaned the challenge of identifying and complying with different clinical care guidelines in markets served by multiple plans. She shared how each plan dictated different clinical guidelines and procedures and the fact that coverage for many services – particularly those associated with certain specialties like cardiology – was hard to ascertain, often not a covered benefit, and ended up being a patient responsibility frequently borne by the provider.

The ability to accurately identify benefits and reimbursement amounts on a timely basis – combined with clear clinical guidelines – was identified as a key means to control overall costs while at the same time doing the best for the health and well-being of the patient/member.

Length of Time a Person Remains with a Single Payer/Plan

One individual associated with a health plan noted the hesitance of funding preventative care for plan members who may not remain with the plan for more than a short period of time. For payers and care providers in risk-sharing arrangements, the cost of preventative care interventions is not typically recouped in a plan year.  They noted the likelihood of benefits associated with proactive care accruing to subsequent plans and the need to compensate clinicians and payers for delivering preventive care whose benefits are derived over multi-year periods. A topic for future discussion would be to explore the policy levers that could help to address this issue.

Impact of No Surprises Act on Provider Networks and Payment Integrity

The roundtable transitioned the discussion to the No Surprises Act where participants discussed what impact the No Surprises Act might have on the future of provider networks and reimbursement. MultiPlan’s Kurt Fullmer shared a quick overview of the Qualified Payment Amount component of the No Surprises Act and participants continued discussing the following related considerations:

Qualifying Payment Amounts as Regional Values Subject to Negotiation

QPA’s are regional values set by both providers and payers in a particular area that will be subject to a ‘baseball-style arbitration process if not mutually accepted by providers and payers.

RELATED: What is a Qualifying Payment Amount?

Compliance with State vs. Federal Regulations & PolicyQualifying Payment Amounts as Regional Values Subject to Negotiation

The need to understand and reconcile the federal No Surprises Act with state-level regulations was also discussed. One participant, a finance leader for a health system in southern California where out-of-network billing and payment law AB 72 has been in effect since 2017, noted ‘little to no non-compliance’ and expected the same with the No Surprises Act. Another participant, a leader at a PPO & IPA in the state of Washington, noted a similar experience with that state’s Balance Billing Protection Act that went into effect in January of 2020.

Removing the Patient from the Middle of Payer-Provider Payment Disputes

Kurt offered that in the interest of goodwill and patient experience, payers and providers may want to remove the patient from any payment dispute process as soon as possible.

Will Administrative Cost of Independent Dispute Resolution Force Providers to Join Networks?

While two participants noted that disputes are rare in their states which have already implemented surprise billing regulations, they and other participants agreed that direct costs associated with the dispute resolution process – and indirect costs associated with patient experience – are not insignificant and would be a consideration by any stakeholder entering dispute resolution.

One participant proposed that costs associated with dispute resolution – both direct and possibly more so with indirect patient experience costs and pressure from health systems – may force many currently non-contracted providers to join plan networks. Another participant disagreed and noted the ongoing physician shortage exacerbated by the pandemic supports non-contracted providers’ reluctance to join networks.

What Enablers Must Be Achieved to Realize Fair & Equitable Payment

The final topic Ferris presented to the roundtable was to solicit perspectives and feedback on what enablers need to be in place to achieve the overall goal of a fair price for a fair service in the most frictionless way possible. Participants agreed that while regulations cannot be ignored, that establishing common definitions, increasing meaningful collaboration and understanding between payers and providers, and working together to build transparent provider networks are primary enablers to achieve fair and equitable payments that address patient needs.

Listen here to Andrew Cone on the need for standard definitions as enablers of fair and equitable payment. [40:40 – 42:28]

Building a Fair and Equitable, Structurally Sound Payment System

If nothing else, this first roundtable on payment integrity and provider reimbursement clarified that the healthcare payment system remains broken with several long-standing structural issues that must be addressed. HCEG’s Ferris Taylor proposed that healthcare needs a solid, ‘concrete’ payment system foundation capable of withstanding the ongoing ‘huffs and puffs’ of various Big Bad Wolves involved with the current payment system: cost-shifting between stakeholders, misaligned incentives, unfair market pricing leverage, complex subsidies, and an increasing number of often ill-defined and conflicting government regulations and mandates – among other things.payment integrity value-based-care

More on Payment Integrity & Provider Reimbursement

payment integrity data and analytics costs and payment hcegWe appreciate Andrew Cone and Kurt Fullmer as thought leaders from our Focus Area Partner MultiPlan and look forward to our next roundtable on Payment Integrity: Data & Analytics for Costs & Payment. In this second roundtable on October 20th at 3:00 Pm ET / 12:00 PM PT, we’ll discuss more specific considerations and practical approaches to building a fair and equitable, structurally sound healthcare payment system.  Leaders of health plans, health systems, and care provider organizations are invited to join.  Request an invite here

Learn more about other Focus Area Roundtables here and consider joining our upcoming webinar series where information and thought leader insight and opinion of healthcare executive priorities will be presented.

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RELATED: Payment Integrity: Supporting Frictionless Services & Outcomes at Fair Prices

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Payment Integrity: Supporting Frictionless Services & Outcomes at Fair Prices

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Historically, payers and providers have maintained ‘arm’s length relationships’ with each party acting in accordance with what they deemed their own best interest. Both parties were wont to hold on to data and processes each deemed proprietary to their business model. Or if shared might be harmful to their market position and operating margins. At worst, payers and providers may engage in antagonistic relationships and point fingers at each other when their members and patients complain. Nowadays with the increasing adoption of value-based payment models, mandates such as the Transparency in Coverage Rule and No Surprises Act, and the entry of non-traditional payers and service providers, it’s critical that payers and providers collaborate with each other, share information in ways beneficial to everyone involved, and recognize their mutual survival depends on using data and technologies to offer a fair service at a fair price in the most frictionless way possible.

Fair Service at a Fair Price in the Most Frictionless Way Possible

There are many considerations, challenges, and actions involved with defining what constitutes a fair service and a fair price – and several traditional and emerging points of friction between stakeholders that must be acknowledged and addressed. The No Surprises Act and the Information Blocking rule in the 21st Century Cures Act are examples of broad regulatory attempts aimed at reducing payer and provider friction with healthcare consumers and patients. Additionally, the increasing use of telehealth services, changes in CMS reimbursement for various settings including home health and skilled nursing facilities, and continuing growth in the use of high-cost drugs are just a few of the reasons for adopting payment integrity programs.

RELATED: Surprise Billing and the Impact for Payors

Payment Integrity: Balancing Cost Savings & Reducing Provider AbrasionPayment Integrity. Payer Provider Reimbursement. Fair Price. Accuracy. Appropriateness. Timeliness. MultiPlan.

It should be no surprise that the amount paid for a specific healthcare service – or outcome in the case of value-based care – can be a key point of friction between payers and providers. Accuracy, appropriateness, and timeliness comprise individual legs of the three-legged stool of fair price. And each of these legs presents specific technical, clinical, and organizational challenges that payers and providers must understand and address – whether in a fee-for-service or value-based arrangement and whether paid retrospectively or prospectively.

To build a strong foundation supporting fair services at fair prices in the most frictionless way possible, payers and providers must balance the maximization of savings from payment integrity programs with minimizing provider abrasion.

RELATED: Trends that are re-shaping payment integrity strategies

Get Answers to Your Questions & Share Your Insight & Ideas

Our 1st Focus Area Roundtable on Payment IntegriPayment Integrity. Payer Provider Reimbursement. Fair service at a fair price in the most frictionless way possible. Transparency in Coverage Rule. No Surprises Actty offers a forum for all participants to discuss topics and ask questions pertaining to reimbursement, payment integrity, and provider networks including:

  1. How can providers and payors find common ground in terms of setting prices and reimbursement?
  2. In what ways will the No Surprises Act change the future of provider networks?
  3. How must payment integrity programs evolve to ever be considered by providers as fair?

Join other healthcare leaders and changemakers on Thursday, September 9, 2021 at 11:00 AM PT / 2:00 PM ET for the first of a series of roundtables facilitated by our Focus Area Partner MultiPlan. Request your invitation today.

Intelligent care management technologies. Value-based care models. Whole-person care. Patient engagement. VirtualHealth HELIOS.

Intelligent Care Management Technologies: Key Considerations & Opportunities

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As the healthcare delivery system continues to embrace value-based care and payment models, a number of factors are driving the adoption of intelligent care management technologies by health plans and other payers. Healthcare consumers, patients, and employers are recognizing the importance of whole-person care and demanding more cost-effective, personalized engagement. Traditional service settings are changing with large increases in telehealth and digitally based services. And more and more non-traditional providers are offering medical and non-medical services – often in the home. All these factors – and others – demand an operating ecosystem with intelligent care management that supports scalable collaboration and coordination between all stakeholders.

Collaboration and Coordination: Foundation of Whole-Person, Value-Based Care

A digital ecosystem that supports clinical, financial, and administrative needs of all stakeholders in a collaborative and coordinated fashion is a foundational component needed to deliver whole-person care – whether those services are provided under fee-for-service and value-based care payment models.

No longer is it sufficient for just physicians, clinicians, and traditional care managers to have access to patient information and be involved with care planning and delivery. Nowadays, the patient themselves, their caregivers and family members, and other new types of care coordinators and service delivery organizations must be included. Additionally, multiple administrators and supervisors play increasingly important roles in care planning, service delivery, and post-care coordination and management. The ability to connect, support, and manage all these stakeholders in a collaborative and coordinated fashion is critical.

RELATED: Optimizing Care Management Through Whole-Person Care

Why do Health Plans Need Intelligent Care Management Technologies?

Health plans have historically collected and received patient data from the majority of the care providers their members are seen by. And, starting in January of 2023, the Interoperability and Patient Access final rule (CMS-9115-F) requires providers to send their entire patient medical record to a patient’s current health plan. Based on this history and new regulations, health plans that integrate, support, and scale intelligent care management technologies to support 360º whole-person care – particularly under value-based care models – can advance their market position by incorporating additional data and entities in their care management facilities:

  • Social determinants and behavioral health issues
  • 3rd party data sources and insights from advanced analytics like machine-learning and artificial intelligence
  • Non-traditional entities including community-based organizations and other non-medical service providers

RELATED: Health Plans as Primary Connection for Patients & Healthcare Consumers

Key Components of Intelligent Care Management PlatformsIntelligent care management technologies. Value-based care models. Whole-person care. Patient engagement. VirtualHealth HELIOS.

And health plans utilize many different platforms and point solutions to support their members and the provider networks that serve their members. These operating ecosystems are almost always a combination of commercial off-the-shelf, bespoke, and point solutions – and hybrid platforms cobbled together over many years. Regardless of the composition, intelligent care management demands certain core capabilities – all of which should support one or more points of the Quadruple Aim:

Better Outcomes & Population Health

  • Built-in utilization management tools with access to a broad set of member/patient data
  • First-level assessments that automatically drive subsequent workflows
  • Ability to access and coordinate admissions, discharges, and transfers (ADT) events
  • Out-of-the-box, configurable, validated assessments incorporating non-clinical risks

Improved Patient Experience

  • Ability to manage and maintain close interactions with individuals across every setting of care
  • Built-in, HIPAA-compliant services including telehealth capabilities
  • Targeted, proven, and personalized approaches to manage the health of various populations on a timely and scalable basis
  • Integration with IVR and third-party digital technologies, wearables, and connected devices

Reduced Cost of Care & Better Financial Outcomes

  • Multi-source data interfaces and aggregation
  • Robust rules engines supporting clinical, administrative, and financial processes
  • Intelligent application of robotic process automation (RPA) tools
  • Integrated with community resources and non-traditional social determinants data

Improved Clinician Experience/Care Team Well-Being

  • Advanced analytics proactively integrated into payer and provider workflows
  • Data and services that support and enhance provider care delivery services
  • Intelligent insights: event-driven and delivered across the care management continuum
  • Automated, workflow-enhancing services/tools – particularly in utilization management and related services

Non-Functional Aspects of Intelligent Care Management Technologies

Realizing the benefit that intelligent care management technologies can deliver is not always an either/or decision and each health plan has unique needs. In addition to the above and other key functionality and considerations, there are several non-functional considerations to consider when evaluating intelligent care management opportunities:

  • Timelines for implementation and the ability to rapidly deploy
  • Ability to retain and leverage existing data and assets
  • Product configuration capabilities
  • Ability to swiftly adapt to new business opportunities and stay compliant with evolving regulations
  • Potential to incorporate new, best of breed applications

RELATED: Top 3 Capabilities Health Execs Need in Care Management Technology

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To learn more about how intelligent care management technologies can help health plans achieve the Quadruple Aim, join us on October 7, 2021 at 12:00 PM PT / 3:00 PM ET for an HCEG Webinar Series event: Intelligent Care Management Technology: Driving Alignment Towards the Quadruple Aim.

HCEG leader Ferris Taylor and Sue Powers, a long-time executive of VirtualHealth, will discuss select intelligent care management technologies and how they can help health plan/payer organizations compete in our rapidly evolving and often uncertain health care delivery system.Provider Onboarding Processes. Appian. The Doctor Can’t See You Now: New Ways to Speed Up and Improve Provider On-Boarding. HCEG Webinar Series Event. Healthcare Executive Group. Low-code platforms. Provider On-Boarding onboarding. physician revenue, provider directory inaccuracies, denials. revenue cycle. credentialing verification. RPA robotic process automation AIRegister now for this live webinar and bring your questions for the Q & A session at the end of the webinar. All registrants will receive a recording of the webinar.

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Practical Interoperability Part 2: Trust, Workflow, Value-Based Care Models, & More

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‘Practical Interoperability’ means different things to different healthcare stakeholders. In the HealthCare Executive Group’s first Focus Area Roundtable on Interoperability, leaders associated with health plans, care providers, and organizations supporting the healthcare system discussed what practical interoperability means to them. Addressing barriers to interoperability and use cases with the most potential to increase interoperability was a primary focus of the roundtable with highlights shared in the first post recapping the roundtable titled ‘Discussing Barriers to Healthcare Interoperability, Use-Cases, and More.’ This second post shares additional highlights including increasing adoption of use cases, the importance of trust among stakeholders, interoperability’s increasing impact on value-based arrangements, and workflow considerations – particularly in terms of balancing the amount of information exchanged by payers and providers.

Read Part 1 of the recap of this first Focus Area Roundtable on Interoperability here.

Importance of Establishing & Maintaining Trust to Overcome Barriers to Practical Interoperability

Building on discussion of the importance of health plan-provider collaboration and which stakeholders are best positioned, qualified, and equipped to own specific interoperability use cases, HCEG’s Ferris Taylor noted the abundance of EMR’s, robust data sets that increasingly include structured clinical data, and analytical capabilities that weren’t available 12-15 years ago. These data and analytics, along with mandates on transparency and interoperability – particularly electronic prior authorization and pricing data – are forcing stakeholders to increase trust among themselves and other 3rd parties.

Ferris asked Tim Capstick, Regional Vice President of Health Plans at Surescripts, to frame the discussion of developing trust to unlock the value of increasing practical interoperability.

Developing a Trust Framework to Unlock the Value of Existing Healthcare Data AssetsTransparency in Coverage Mandate. No Surprises Act. health plans, health systems, healthcare providers. compliance-related activities. Data Standards, Data Collection & Operational Considerations

Tim set the context for roundtable comments by sharing how well-defined standards, clearly understood use cases, and trustworthy partners serve as the essential foundation to maximize business model benefits of increased interoperability. Tim emphasized: “We have to be able to trust whoever’s going to sit in the middle – or bring these entities together. We’ll have to be able to trust each other and make sure that we know and trust what each other are going to be doing with this information.

Listen here for more on establishing trust to unlock the value of healthcare data

RELATED: Building Trust is Essential to Transforming the Healthcare System

Establish Trust by Consistently Providing Quality Information That Returns Value

One participant representing a research organization shared that standards – particularly FHIR – will help with advancing practical interoperability once the data content, elements and formats of these standards are better understood.

Participant Denny Brennan, Executive Director and Chief Executive Officer of HCEG partner Massachusetts Health Data Consortium (MHDC), weighed in on the importance of by sharing that MHDC is creating an implementation guide combining DaVinci-compatible payer data and clinical data exchange standards related to prior authorization.

Denny noted that payers and providers have a great deal of work getting their digital house in order and making the necessary data available to accelerate instantaneous or close to instantaneous prior authorizations for services that today are difficult, arduous, and don’t require a huge amount of clinical intervention, if anything, to make the decision.Healthcare Price Transparency Price Transparency Regulations & Compliance, Policies, Programs, & Tools, Data Standards & Operational Considerations

Listen here for more on the importance of providing quality data to healthcare providers

See Price Transparency Data Standards & Operational Considerations from a recent roundtable in Price Transparency facilitated by our Focus Area Partner HealthSparq.

Balancing Amount of Data Shared with Providers – Increasing Impact of Value-based Arrangements

Other discussions involved challenges, issues, and opportunities regarding interoperability’s impact on the day-to-day workflow of healthcare stakeholders – particularly in terms of how care providers are accessing information and what information is being presented. The balance between providing too much information that can overwhelm care providers, administratively burdens them, and inhibits their ability to do what they need to do and responding to provider requests for more information to make care decisions were discussed. Participants noted value-based arrangements and risk-based reimbursement models are clearly an impetus for increased interoperability and drive desire from the provider community for more information. Being mindful of the process workflow of care providers, what information is inserted into the workflow, and how that information is inserted and accessed was identified as key considerations.

RELATED: How Health Plans Can Best Support Provider Organizations Address Barriers to Practical Interoperability

The Importance of Breaking Workflow to Include Business Partners

Roundtable participants made clear that accommodating care provider information demands – whether under traditional FFS or new value-based payment models – requires a thoughtful change to provider workflows. In addition, compliance with interoperability mandates and realizing practical interoperability’s greater benefits means all stakeholders will need to break their routines and [modify] their workflows to include partners.

“Stakeholders don’t have to do this themselves if they can get out of the adversarial zero-sum game that, if we share data with providers, or we share data with health plans, they are going to use those data against us or whatever scenario comes to mind. There’s a lot of money that’s being swept off the table by IT vendors who are offering niche services that ultimately never get used.” – Roundtable Participant

As shared in the Part 1 recap of the roundtable on interoperability, if providers invested in better collaboration with their payers, they might reduce their investment in the technologies to support processes they thought they were going to do entirely by themselves.

Listen here for more on breaking business partner workflow to reduce overall IT investments

Interoperability Vendors Serving the Healthcare Market – a Darwinian ExperimentDarwinian experiment interoperability-related initiatives, programs, and applications.

Participants shared various comments about increasing the adoption and evolution of interoperability-related initiatives, programs, and applications.

One participant shared his observation that, on the intervention side, increased interoperability is empowering many great third-party companies that are already doing great work around mobile engagement, disease management, and so on.

“There’s a whole bunch of them. There’s been a sort of Darwinian experiment of all these different vendors about what approaches to take and we’re starting to see some rise to the top; to create the ability for them [providers] to sort of socket in a secure way and play on the platform and do things for the benefit of patients.”

Another shared that healthcare stakeholders have a collective obligation to create a competitive environment for the adoption of practical interoperability:

“I think when we talk about interoperability, we have just not a responsibility but really an obligation to create a competitive environment where they can come and play and let the best continue to rise to the top.”

And another shared a suggestion to healthcare providers who think they can avoid sharing their healthcare data.

One of the steps that we have to really focus on in terms of what do payers and providers have to do is: stop thinking you have to do everything yourself. You’re going to have to share data. Forget about arguing about that. Forget about it. You’re going to have to share everything. The deal is done. It’s over. You’re going to have to be transparent, get over it, stop complaining about it.”

And now, healthcare requires payers and providers are going to have to really start thinking about creating new, collaborative business models that engage consumers. And if they don’t do that and each go after the consumer in their own way, they’re just complicating the problem we have today which is: I want to go to one place to get all my health data. The fact that it’s a health plan as envisioned in the regulation should not preclude any progress.

Quality Measures: Data Requirements, Costs, & Impact of Upcoming Changes

A participant from a small health plan noted the number of new hybrid measures related to telehealth services and how interoperability mandates and related initiatives will impact provider collection of quality measures and submission to health plans; particularly as the CMS deadline for transition to all-digital quality measures takes place in 2025 and information currently being collected goes away.

Sharing Information – It’s the Law & The Right Thing to Do

This participant representing a small health plan expressed concern about the number of EMR systems in use at health systems, the overall lack of awareness, understanding and adoption of interoperability mandates among the provider community, and the challenges that present health plans – particularly smaller health plans – with accessing data from health systems.

She mentioned the cost impact of both complying with interoperability mandates and how some providers and health systems charge for access to data housed in their individual EMR’s.

“We’re sitting here knowing that our entire world is going to digital, knowing that we have to get to digital, seeing interoperability as one opportunity for everybody collectively to get to digital. But the adoption rate is The Big Question in my mind.”

Listen here to the leader of a small health plan share insight on accessing data

Information Blocking – Serious Consequences for Non-Compliance

Information Blocking. Section 4004 of the 21st Century Cures Act. Electronic Health Information (EHI). USCDI Version 1. Regulations. Interoperability

Source: Office of the National Coordinator for Health Information Technology (ONC)

Existing regulation concerning Information Blocking (Section 4004 of the 21st Century Cures Act) was raised with one participant noting that charging fees for accessing, exchanging, or using Electronic Health Information (EHI) – with exception per 45 CFR § 171.302 – is a felony.  He noted that while a smaller subset of EHI data (elements defined in USCDI Version 1) is currently subject to Information Blocking through October 5th, 2022, regulations expanding those data elements to USCDI version 2 are quickly approaching and the regulated community should make all EHI available as if the scope of EHI were not currently limited to Version 1.

Patience for Non-Compliance with Information Blocking Regulations is Decreasing

This topic of discussion was ended with this participant saying:

“And CMS and the [Biden] Administration have shown absolutely no patience whatsoever with that stance. So, I think health plans who were finding themselves running up against EMR’S who are trying to monetize data and the availability of data from their records, have the weight of the law behind them. Providers who try to monetize their data exchanges with health plans directly is not okay unless it’s purely at cost or something very close to at cost if it’s an extraordinary effort. And going forward it’s not going to command a very high premium to get data from the provider who’s treating a member.”

Listen here to a healthcare data expert on provider reluctance to share data with health plans

Learn More About Practical InteroperabilityPractical Interoperability. Electronic pre-authorization. Surescripts. HealthCare Executive Group. HCEG. Focus Area Roundtable. health plans, payers.

On September 8th, 2021, leaders of health plans, health systems, and provider organizations will have the opportunity to discuss the real-life initiatives, programs, applications, and technologies their organizations are considering, implementing, or currently using to address the challenges, issues, and opportunities recapped here and in the first post of this two-part series.  Leaders of health plans, health systems, and provider organizations are encouraged to request an invite here.

Special thanks to Ashley Clark and Tim Capstick of our sponsor Surescripts for sharing their unique insight in this roundtable. For information on any of the topics presented in this post, contact Tim Capstick or Ashley Clark.

To receive additional information on interoperability and other healthcare leader priorities presented on the 2021 HCEG Top 10+ list, subscribe to our newsletter and follow us on Twitter and LinkedIn.

Barriers to Interoperability. Health plans, payers, care providers. Mandates. data transparency, information blocking, HIPAA regulations. Surescripts. Use Cases. Prior Authorizations. Electronic prescribing. Medications. Surescripts

Discussing Barriers to Healthcare Interoperability, Use-Cases, and More – Part 1

By | Events, Focus Area Roundtable, HCEG Content | 2 Comments

‘Interoperability’ – particularly between health plans and care providers – has been a high priority of healthcare executives for years. It ranks #6 on the 2021 HCEG Top 10+ list and has an impact on almost every area of healthcare. And recent, still evolving mandates regarding data transparency, information blocking, changes to current HIPAA regulations, and interoperability have placed significant challenges upon the health plans, provider organizations, and the technology partners serving the healthcare industry. Forward-thinking stakeholders are not considering mandates as barriers to healthcare interoperability but rather viewing compliance with mandates as opportunities for ensuring the ongoing viability of their healthcare business models.

In our first Focus Area Roundtable on Interoperability held Tuesday, July 20th, and facilitated by our Focus Area Partner Surescripts, leaders from health plans, health systems, and healthcare provider organizations shared their experience, insight, and information in a roundtable fashion on the topic of Interoperability. Surescripts Tim Capstick and Ashley Clark served as industry thought leaders providing their perspective on these interoperability-related topics, in particular from a health plan point of view.

This post presents the first part of a 2-part series sharing highlights of this first roundtable on interoperability. Leaders of health plans, health systems, and provider organizations are encouraged to participate in upcoming Focus Area Roundtables including the 2nd Interoperability roundtable on September 8th, 2021.

Read Part 2 of the recap of this first Focus Area Roundtable on Interoperability here.

Barriers to Healthcare Interoperability Payers & Providers are Encountering

HCEG’s Executive Director Ferris Taylor kicked off the roundtable by asking participants: What are the barriers to healthcare interoperability that health plans and health systems are encountering with respect to the broad topic of interoperability?

Consent Management – One of the Barriers to Healthcare Interoperability

One participant noted that when deploying interoperability solutions, one of the biggest challenges involves consent management for members and patients. Appropriately managing patient data and providing individuals the ability to weigh in on the sharing of their data is both a technical and policy problem. He noted while their organization is addressing consent management largely on their own, he expects the evolution of privacy laws in California and Europe will likely have a national impact across the United States.

Another participant shared that addressing consent management is key to the future of interoperability – not just between members/patients and their health plan and providers but also when providers are sharing information with other health systems/healthcare providers.

Listen here for more on the importance of consent management in advancing interoperability

Other Barriers to Interoperability for Health Plans and ProvidersHCEG HealthCare Executive Group focus area roundtable Barriers to Healthcare interoperability poll

Participants were presented with a list of potential barriers to interoperability and asked to select two barriers from the perspective of a health plan and a provider.

For health plans, Access to and Integrating Data Sources ranked first followed by Complex Privacy and Security Concerns.

For providers, Internal Challenges with Technology and a Lack of Knowledgeable Resources were identified as key barriers to healthcare interoperability.

Impact of Proposed Modifications to HIPAA’s Privacy Rule on Interoperability

Surescripts Ashley Clark shared that data rights are an issue her organization takes very seriously and that they’re currently looking at CMS legislation regarding expanding the definition of treatment under HIPAA and what information can be shared as medical treatment versus non-treatment. Ashley shared that pending regulation changes will likely open up a lot of doors in terms of information that can be shared on things like medication history.

Another participant shared his perspective on barriers to healthcare interoperability for payers and providers by sharing that from his vantage point he’s seeing tremendous reticence on the part of providers to address interoperability and data transparency in any deep way vis-à-vis their health plan partners; with the exception of some relationships forced by the COVID pandemic.

Who Owns Health Plan Member and Provider-Patient Data?

Health Plan Best Positioned to Own Data - HCEG-Industry Pulse Research Survey 2020

Data Ownership – 2020 Industry Pulse Report

The recent announcement by the Biden Administration to increase penalties on providers who are not making their pricing information available was identified as the first step toward breaking the long-held, culturally ingrained notion that patient care and the information generated from that critical activity belongs to the health system and to the provider community alone.  It was noted cultural acceptance – on the part of both payers and providers – that their existing business models are built on a largely zero-sum game is a large barrier that must be overcome in order for practical interoperability to be widely adopted.

Note: Respondents to the 2020 Industry Pulse Report shared their take on data ownership between payers and providers. See survey results in the graphic on the right.

Listen here to a roundtable participant discuss data ownership among health plans and providers

“Culture eats technology. Culture eats strategy. Culture eats operations. Culture even attempts to eat policy for lunch.” – Roundtable Participant Denny Brennan – Executive Director & Chief Executive Officer of HCEG partner Massachusetts Health Data Consortium

Health Plans as Primary Connection for Patients & Healthcare Consumers

The concept of data hoarding by providers and payers was discussed along with the idea that it’s easier for health plans to surface data than it is for providers to do so. January of 2023 – just over two years away – was noted as a deadline for providers to share almost all of ‘their data’ with health plans. Per the Interoperability and Patient Access final rule (CMS-9115-F), providers will have to send the entire patient medical record to a patient’s current health plan because that health plan is responsible for moving that to the patient’s next health plan.

“I know a lot of regulators and a lot of providers around the country have not yet internalized the idea that the primary connection for the patient is going to be the health plan and that providers are responsible for providing the health plan all the clinical data that’s necessary to maintain that connection. And to inform the patient and make it possible for payer-to-payer connectivity to work.”

RELATED: Key Interoperability, Health Information Technology, and Transparency Policies

How Health Plans Can Best Support Provider Organizations Address Barriers to Healthcare Interoperability

“If I were running a medical group or a community hospital, one of the first things I’d be thinking is:

  • How do I sit down with my major payers and figure out what I can upload?
  • What am I doing that I don’t have to do that payers can pick up with me?
  • How do I cement that partnership by taking over pieces of the business that they insist on taking over that I’m better equipped to do like delivering care to the patient?

I’m the one who’s going to engage the patient. Give me tools, help my staff get trained so that the doctor doesn’t have to talk to the patient about SDOH or the doctor doesn’t have to talk to the patient about their financial exposure.”

Listen here for more on how health plans can help healthcare providers enhance interoperability

Use Cases with Most Potential to Increase Interoperability

Ferris asked participants to share their insight on which use cases might best advance interoperability and improve payer-provider-patient/consumer collaboration.

Increasing Consumer Ownership & Assisting Stakeholders Serve Their Members/Patients

A health plan participant shared that the use cases he sees that have the most impact potential are ones that lead to an increased amount of consumer ownership and activation of the health system to serve the member/patient. He noted that the process of effecting these use cases requires healthcare organizations to face some level of deconstruction. He explained that addressing barriers to interoperability in healthcare means that everyone has to have a relationship with everyone else when it comes to data – and some organizations are uncomfortable with that. So, we have more work to do.

Automating High Friction Activities & Improving Patient Engagement

Another participant shared that his organization separates use cases into two major buckets. One in the realm of automating high friction activities between payers and providers. Frequently occurring activities that can be automated and that are happening in every other industry. And the other in the realm of interventions, population health, or value-based care efforts that actually improve care like patient engagement, chronic disease management, telemedicine, etcetera.  For each bucket he emphasized the importance of each use case:

  • Being capable of being rolled out on their own and in a stepwise fashion to get to some ideal future state.
  • Having deployable value on its own and being able to stand on its own.

As an example of the bucket on the automation side, one of the first things healthcare organizations should address is auto eligibility because something like three-quarters of the calls from providers to their payers is some flavor of eligibility. And, except for a long tale of rare cases, a lot of that is totally automatable.

In a recent Focus Area Roundtable facilitated by HealthSparq, participants discussed how new price transparency mandates will likely help drive opportunities for increased engagement between providers and their patients. Read more about this potential in Payer-Provider Collaboration Critical to Meeting Price Transparency Mandates.

Reshaping Patient Relationships with Providers

Another participant shared that their personal experience is that the patient-provider relationship is typically a transactional relationship – often a negotiation on a chargemaster – and that increased interoperability seems to have the potential at least to change that quite dramatically.

Most Impactful Use Cases Identified by Focus Area Roundtable Participants

After discussing interoperability-related use cases, participants responded to a poll on ‘Which interoperabiliHCEG HealthCare Executive Group focus area roundtable Barriers to Healthcare interoperability Use Cases pollty use cases offer the most opportunity to advance patient-payer-provider collaboration?’ This question was asked from the perspective of both health plans and providers and the following were equally ranked for both health plans and providers:

  • Shortening or Automating Prior Authorizations
  • Providing Pricing Data to Patients & Providers

Electronic Prior Authorizations – Webinar on August 25th at 2:00 PM ET

Automating the processing of prior authorizations via ‘electronic prior authorization’ (ePA) – particularly in settings like the pharmacy where a patient may be waiting – can significantly enhance patient/member engagement by reducing the time between a request being made and a patient receiving care. To learn more about the Fast Prior Authorization Technology Highway (Fast PATH) initiative launched by AHIP and several health plans, consider attending Electronic Prior Authorization: The Fast PATH Towards Better Patient Care on August 25, 2021 at 2:00 PM – 3:00 PM ET.

Cutting Through Administrative Chaos by Focusing on Specific High-Value Use Cases

Surescripts Ashley Clark shared some actions that can be performed to cut through the chaos of everything that’s going on administratively at health plans and provider organizations. These included:

  • Driving adoption and usage of a limited set of use cases by getting very specific about those use case
  • How achieving success with a limited set of use cases can lead to bigger decisions across the board.
  • Being very detailed about the information that is being shared back and forth so that it’s not seen as if irrelevant information were overlooked

Listen here for more from Surescripts Ashley Clark on cutting through administrative chaos

Plans and Providers Working Together to Avoid Duplicative Efforts

One participant whose organization is closely engaged with supporting provider organizations shared that when meeting with providers and health plans they talk regularly about “You both are doing the same things, you call them the same things. They’re a little bit different but why are you both doing Population Health Management?” He commented: “I don’t understand why people who are battling it out on engaging the patient are battling it out on collaboration at the level of administering clinical process.”

Who’s Best Positioned, Qualified, and Equipped to Own Specific Interoperability Use Cases

After discussing interoperability-focused use cases, roundtable participants shared their take on additional considerations regarding involvement and ownership. The following points were raised:

  • Health plans are much better equipped to do population health management.
  • Providers are much better equipped to deal with care requirements and patients in real-time.
  • Everybody is investing in systems that are enormously expensive.
  • Providers are spending a lot of money on tools that if they had better collaborative relationships with payers, they wouldn’t have to invest in.

Payers and providers each need to ask: What does practical interoperability mean for our business and how do we design our businesses?

Listen here for more from roundtable participants on interoperability-related use cases

Informing Care Decisions & Providing Insights to Either Side of the Network

As an individual who works directly with payers and who has colleagues working directly with providers, Tim Capstick shared that Surescripts tends to focus on informing care decisions, providing insights across the network to both sides of the network, and enhancing the prescribing process for providers.

Tim shared that on the payer side there is a lot of concern and issue around the consistency in which providers are utilizing enhanced prescribing services, what providers are getting out of prescription services enhanced by interoperability and the overall return on investment? And on the provider side: what is the quality of this information that’s being presented? Is data consistently being presented and can the data be trusted?

Listen here for more from Surescripts Tim Capstick on informing care decisions and increasing the adoption of interoperability use cases.

Additional Interoperability-related Topics of Discussion – Coming in Part 2

The first Focus Area Roundtable on Interoperability facilitated by Surescripts covered a lot of areas of interest to participants – way more than can be reasonably shared in a single post. In the second part of this two-part recap, information on the following will be shared:

  • Trust, quality, and scarcity as a mechanism for increasing adoption of interoperability use cases
  • The importance of balancing the amount of information payers share with providers
  • Interoperability’s increasing importance and impact on value-based arrangements
  • The importance of workflow
  • An interesting comment about charging for access to healthcare data and how another participant responded

Come Learn More & Share Your Insight

Our second Focus Area Roundtable on Interoperability takes place on Tuesday, September 8th at 10:00 AM PT / 2:00 PM ET and will build upon the topics shared in the first roundtable. In addition, our Focus Area Partner Surescripts will share information on and respond to participant challenges, issues, and opportunities regarding interoperability collected in advance of the roundtable.  Leaders of health plans, health systems, and provider organizations can request an invite here.

Special thanks to Ashley Clark and Tim Capstick of our sponsor Surescripts for sharing their unique insight in this roundtable. For information on any of the topics presented in this post, contact Tim Capstick or Ashley Clark.

To receive additional information on interoperability and other healthcare leader priorities on the 2021 HCEG Top 10+ list, subscribe to our newsletter and follow us on Twitter and LinkedIn.

Payer-Provider Collaboration Critical to Meeting Price Transparency Mandates

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  • Ignoring price transparency mandates will not make them go away

  • Will the No Surprises Act be the dagger in the heart of fee-for-service payments?

  • What changes to the No Surprises Act may be coming? And when?

  • Will Advanced EOB’s force payers and providers to collaborate more?

  • How might price transparency impact the workflow of health plans and providers?

  • Will price transparency regulations help patient engagement? Or create a customer service nightmare?

Our second Focus Area Roundtable on Price Transparency – facilitated by HealthSparq – took place on Wednesday, June 16th and members of the HCEG Network and industry thought leaders including Denny Brennan, Executive Director and Chief Executive Officer of HCEG partner Massachusetts Health Data Consortium (MHDC), raised and explored these and other questions.

Ferris Taylor kicked off the roundtable by asking Matt Parker, Vice-President of Products at HealthSparq, to frame the conversation by sharing a highlight of the keynote presentation “Path to Transparency – Increasing Access, Lowering Costs, and Driving Value that Matt presented along with two other healthcare leaders at the World Health Care Congress Virtual 2021 conference.

Price Transparency – Part of the Foundation for Patient Engagement

Matt Parker related that the Transparency in Coverage Mandate and No Surprises Act presents unique challenges for health plan payers and providers that can only be addressed via increased collaboration. Matt shared that price transparency is just a tool, a component to facilitate payer and provider interaction with their members and patients – not an end in itself but rather something for helping members, patients and providers better understand available provider networks, find care when they need it, engage with the system, and understand what costs are going to be – from both the member, patient, and provider perspective.

Matt suggested this price transparency foundation is the floor on which health plans and providers can build more holistic engagement with their members and patients.

RELATED: Recap of 1st Focus Area Roundtable on Price Transparencyhealthcare transparency in coverage. No surprises act. healthsparq price transparency

Building Upon the Floor Established by Price Transparency Mandates

To build upon the idea of compliance with transparency mandates as the floor, a health plan participant asked: How do we separate the basic needs of meeting the mandate from the next phase once pricing data is out there? And once basic needs are met, how can we then use that accomplishment to do things to support our members to engage with our providers more effectively? How can we help members with their provider relationship?

These few questions and others raised by participants affiliated with both health plans and provider organizations shaped the discussion and interaction throughout the roundtable.

Primary Topics Discussed by Roundtable Participantshealthcare data interoperability surescripts focus area roundtable HCEG

Our Focus Area Roundtables are informal discussions where all participants can contribute insight and raise questions. This post presents a number – but not all – of the contributions made by roundtable participants. Additional content will be shared in future posts, our social channels, and in future roundtables. To receive additional information on this and other Focus Area Roundtables, join our newsletter, follow @hcexecgroup on Twitter, connect with us on LinkedIn, and consider participating in upcoming roundtables.

RELATED: Join our Interoperability roundtable on July 20, 2021 at 10:00 AM PT / 1:00 PM ET

Who’s on First? Low Levels of Initial Compliance Due to Confusion?

One participant referenced a recent study published by JAMA that noted low compliance with the price transparency mandate by hospitals. In response, another participant noted that at his health plan, there was confusion about what is required and who is responsible for compliance with current price transparency mandates.  He noted that some staff were not aware of the upcoming January 2022 price transparency deadline for health plans, or thought it was provider-related, not health plan-related.

To be clear, while there are price transparency mandates for both providers and health plans, the JAMA study referenced the hospital-related mandate effective earlier this year on January 1st. Effective dates for price transparency-related mandates for health plans and the specific capabilities required are noted in the following table:

Transparency in Coverage Mandate – Health Plan/Payer

January 2022 Public access to pricing data through machine-readable files
January 2023 Personalized, out-of-pocket estimates via online, self-service tools
January 2023 Pricing data available for 500 services
January 2023 Pricing data available for all covered services via online tools or print delivery

No Surprises Act – Health Plan/Payer

Cost-sharing price comparison by phone or internet for specific service/item
Advance EOB w/ provider and contracted rate for in-network services. Out-of-pocket cost estimate for Out-of-Network services at least 3 days in advance
Provider directories updated & verified every 90 days w/ info updated within 2 business days of receipt. Health plan process for organizations not responsive to verification attempts.
RELATED: Diving into the Details: What You Need to Know About the Machine-Readable Files Mandate

Ideal Outcomes of Payer-Provider Compliance with Price Transparency Mandates

From a health plan perspective, compliance with price transparency mandates should help providers deliver care more effectively – as viewed by the patient. From the provider’s standpoint, a tighter integration with their health plans should enable providers to answer pricing questions from their patients.

If Mandates are Ignored, Will They Go Away – Or At Least Be Delayed?

Transparency in Coverage Mandate and No Surprises Act

MHDC’s Denny Brennan shared how some provider and payer organizations are viewing the mandates:

‘Perhaps there’s a bit of willful denial about sharing data partly driven by the fact that pricing information has long been held on the provider side in chargemasters, which are notoriously poorly maintained files with respect to what the patient’s actual exposure will be. Providers and plans are still looking at pricing data as part of their proprietary contracting process and may be essentially ignoring the mandate.’

Denny also offered that the idea of sharing pricing data hasn’t settled in across the industry because health plans are waiting for providers to take the lead and many providers are thinking: “We don’t know how to do that, we don’t know if we want to do that, and if we pretend it’s not happening, it may go away – especially because so many things have been pulled back with COVID-19.”

RELATED: Meeting Transparency Mandates: Put Your Employer Groups at Ease

Delays to No Surprises Act – Likely Clarified by August 2021

Ferris asked HealthSparq’s Matt Parker if he anticipated that the payer-side legislation might get delayed. Matt stated that while the Transparency in Coverage rules are finalized in theory, will take place over the next few years as defined, and will likely not be changed, there are not any sufficiently defined rules pertaining to transparency-related parts of the No Surprises Act – including the Advanced EOB requirements.  Matt also shared that updates to the No Surprises Act are likely to be released next month in July.

Listen here for more on potential delays to the No Surprises Act.

Other Mandates Taking Precedence over Transparency?

Participants noted that other regulations, mandates, and rules are taking precedence over – or at least complicating compliance with – the Transparency in Coverage Mandate and No Surprises Act including:

An Old Cliché Rings True: Garbage In – Garbage Out

One participant with decades of experience serving health plans noted that 80-90% of medical bills have errors of some type and this means that price transparency and data sharing mandates are starting from a system that is already error-laden. Accuracy needed to automate information interchange does not always exist and we have to clean up our act before we put it on stage.

She echoed questions posed by her clients:

  • Where am I going to pull this data from?
  • How am I going to get this out of my systems into data files?
  • Who are knowledgeable partners that can help with the generation and hosting of machine-readable files?
RELATED: Understanding the Transparency in Coverage Mandate

Health Plans as Definitive Sources of Health Information

On the topic of who’s best positioned to serve the information needs of members and patients, Denny shared that:

“What we’re telling our members is, and this is a tough message for the provider community, is that the route by which patients/members/consumers will be getting their health data is through their health plan. And the regular interchange and exchange of data between health plans and providers is great for providers who need to manage care. But providers are not envisioned in the rules as being the definitive source of patients/member/consumer health information – that’s going to be coming through their health plan.”

Incomplete and Insufficiently Specified Rules Hamper Meaningful Transparency

Healthcare data includes administrative, clinical, and financial data held by both providers and health plans and subject to HIPAA and other federal and state regulations. Denny shared his take on challenges health plans and providers are encountering due to insufficiently detailed regulations and unresolved elements of payer-provider-consumer interoperability for the purposes of value-based care.

Listen here for more on considerations regarding the current state of interoperability rules.

Advanced EOB’s – Forcing Payer-Provider Collaboration & Impacting Workflow Providers?

Providers need to be able to sufficiently integrate with health plans to get a fairly accurate estimate of the cost of specific procedures. Matt shared his take on the Advanced Explanation of Benefits (EOB) portion of the No Surprises Act and suggests it will force payers and providers to create a technology solution in their workflow.

Listen here for more on the impact of Advanced EOB’s.

RELATED: Advance EOB, Patient/Consumer Protections, and Reporting

No Surprises Act – The Dagger in the Heart of Fee-For-Service?Price Transparency Mandate Kills Fee-for-Service Payment. Value-based payment models

MHDC’s Denny Brennan shared his take on how the movement to more transparency and interoperability mandates may speed the movement to value-based payment arrangements.

“One of the things that I infer from these discussions is that the No Surprises Act is almost a forcing function. As I’ve said to members of our group, if there was ever a dagger, that could be driven into the heart of fee-for-service medicine, it’s the No Surprises Bill. Because in order to prop this thing up and to burden the physician with telling the patient at the point of care that: “Well we want to get you an MRI but if we get it down the street instead of in our own network you’ll save more money.” And physicians hate that. They don’t want to have those conversations. It’s hard enough to get physicians to talk about social determinants of health.

Listen here for more on the potential impact on fee-for-service payment models.

Impact of Increased Transparency on Customer Service

In response to participants’ discussion about transparency mandates forcing greater adoption of value-based care models, Ferris asked whether there might be a consumer backlash based on missing or inaccurate pricing information and how it might be solved. One participant predicted a customer service nightmare for health plans and providers, and another stated that it’s a problem that is going to be solved by a crowd – not by individual organizations.

Listen here for more on the potential impact of mandate compliance on customer service.

RELATED: Price Transparency Resources for Health Plans

Connect with Others Facing Similar Challenges

Special thanks to Matt Parker and HealthSparq for their role as our Focus Area Partner for Price Transparency. For more information on the meeting and exceeding price transparency mandates and to learn more about topics presented in this post, check out HealthSparq’s website and contact HealthSparq here.

If you’re a leader of a health plan, health system, or hospital/provider organization, consider joining future Focus Area Roundtables on Price Transparency, Interoperability, NextGen/Value Payment Models, and Healthcare Policy & ACA. We have other Focus Areas of the 2021 HCEG Top 10+ under development.Healthcare Executive Group Focus Area Partners HealthSparq Softheon Surescripts Zelis

Insight on Using Data & Analytics to Address Healthcare Consumer Needs. HCEG Top 10. Member Data. Insights. Pre-Authorization Process. HCEG. WHCC.

Insight on Using Data & Analytics to Address Healthcare Consumer Needs

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Health plans have more data and analytics than they typically know what to do with.  The challenge is to use new types of data and advanced analytics like artificial intelligence and machine learning to derive insights and actionable information that all stakeholders – healthcare consumers, providers, and payers – can use to facilitate access, improve outcomes, and reduce costs. It’s no wonder that Data & Analytics consistently ranks high on the annual HCEG Top 10 list of challenges, issues, and opportunities facing healthcare leaders.

On Wednesday, April 28, 2021, HCEG Executive Director Ferris Taylor moderated “Use Data to Uncover Insights and Create Actionable Strategies that Address Member Needs,” a webinar hosted by our partner World Health Care Congress with the following healthcare leader panelists:

This post shares highlights of some of the insight, expertise, and experiences shared by the above executives during the webinar. Access a recording of the webinar here and hear from the panelists themselves at the [specified recording time] listed with each of the session highlights presented below.

Strategic Focus on Using Data & Analytics to Find New, Actionable Insights

Ferris Taylor kicked off the discussion by asking panelists to introduce themselves and to share, from a strategic point of view, a quick overview of how they are using data and analytics to find new and actionable insights.

Leveraging Social Determinants of Health

Sherri Zink shared her organization’s focus on improving member engagement by leveraging different data across multiple silos – including social determinants of health data from 3rd parties – to help providers engage with plan members on a more holistic basis.  Listen at [00:04:41]

Anticipating Member Needs & Personalizing Interactions via Workflow

Shawn Wang offered how his health plan is better anticipating members’ needs and personalizing interactions via existing workflows.  Listen at [00:07:30] for more on:

  • Importance of embedding data and AI insight into workflows
  • Personalizing member interactions with personalized care plans, personalized news, and personal topics that address member needs.
  • Reducing overall burden by removing complexity from staff member jobs

Earning Trust of Members By Giving Them Something in Return

Mohammad Jouni shared how technology partners can support health plan member’s medical needs and administrative needs as members are interacting with health plans during other customer service events. Listen at [00:09:37]

RELATED: Leadership, Trust & Skills in Overcoming Obstacles to Radical Innovation in HealthcareInsight on Using Data & Analytics to Address Healthcare Consumer Needs. HCEG Top 10. Member Data. Insights. Trust. Process. HCEG. WHCC.

Uncovering Insights & Actionable Information: Opportunities, Challenges, & Points of Pain

Panelists shared information on the pain points and challenges that their health plan or health plan customers have addressed or still trying to address in making data and analytical tools actionable to support the relationships between the health plan, the consumer, and the provider.

Supplying Business Partners with Meaningful, Actionable Data

Sherri conveyed the importance of taking advantage of teachable moments during member interactions with customer service, capturing and leveraging unstructured data presented during interactions, and making data and analytics available in downstream systems and to provider partners. Listen to Sherri at [00:12:22]

Importance of Thinking About Data from Standpoint of Member, Not the Organization

Many health plans organize their company by functions and not around the member. Shawn shared his thoughts on the importance of a cohesive, end-to-end process, using data from the member’s viewpoint and not from an organizational standpoint, and embedding data and analytics into organizational workflows.  Shawn shares at [00:17:30]

Importance of Member Trust & Trust in the Process

Mohammad talked about the need to earn member trust and how vendors who establish trust with plan members can do a lot for the member that health plans or providers might otherwise not easily accomplish.  Listen at [00:33:33]

Applications Having Greatest Impact from Data & Analytics

Sherry shared insight on what applications are having the greatest impact from improved data and analytics, the need for member trust, and how Net Promoter Scores are impacted. Listen at [00:36:13]

Major Impact on Reducing Duration of Pre-Authorization Process

Shawn shared how high-volume, complex back-office processes like pre-authorization and other utilization management functions benefit greatly from improved data and analytical capabilities. Listen at [00:40:48]

RELATED: Healthcare System Interoperability – The Key To The Care We All Strive For

Vendor Interactions Impact on Health Plan Member Satisfaction

Mohammad stated that closing gaps in care is one of the areas seeing the greatest impact from data and analytics. He noted how new insights on member needs and member interactions with 3rd party vendors and their offerings are positively impacting plan member satisfaction and trust. Listen at [00:43:55]

Integrating New Data into Analytics and Tools Provided to Providers and Consumers

Ferris stated that there are lots of different tools out there and that it seems like data and tools are multiplying every six months. Ferris asked: As health plans, how are you integrating new data into the analytics and the tools that you’re providing to your consumers?

LISTEN to Sherri’s thoughts on the following topics at [00:46:55]

  • Insight on downstream operational systems and legacy applications
  • Making sure data produced in upstream systems is available in downstream operational systems
  • Mapping clinical data, financial data, administrative data – structured & unstructured – on-premises & cloud-based
  • Integrating 3rd party data – particularly social determinants of health

LISTEN to Shawn’s thoughts on the following topics at [00:49:43]

  • Organizing and consolidating data – Key to scaling integration capabilities
  • Capturing insight from audio interactions & acting on that insight near real-time
  • Updating analytic models frequently and timely deployment to downstream systems

RELATED: Healthcare Price Transparency – Leaders Share Insight – Part 1

Attendee Questions on Using Data & Analytics to Create Actionable InsightInsight on Using Data & Analytics to Address Healthcare Consumer Needs. HCEG Top 10. Member Data. Insights. Trust. Process. HCEG. WHCC.

Panelists had an opportunity to respond to questions from webinar attendees. Listen in at [00:53:44] to hear panelist responses on questions pertaining to the following:

  • Co-developing a data & analytics strategy with business partners
  • Defining and ranking use cases across all business units
  • Accommodating member/patient communication preferences
  • Example of addressing high-utilizer of ER services
  • Avoid taking a cookie-cutter approach

Panelists Leaders Share One Piece of Advice on Leveraging Data & Analytics

Ferris concluded the discussion by asking panelists to share one piece of advice on the broad topic of data and analytics. Listen at [01:01:58] for panelists responses on the following topics:

  • Ensure alignment with overall strategy & think through the end-to-end process
  • Start with the outcome you want to achieve
  • Demonstrate value early on

Opportunities for Insight and Interaction with Healthcare Leaders

2021 HCEG Top 10+ Focus Areas Interoperability Healthcare Policy

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Price Transparency Compliance Regulations Mandates. Policies, programs, and tools. Data standards. Operational considerations. Increasing adoption. End-user education and support. Payer-provider relationships.

Beyond Price Transparency Compliance – Stakeholder Thoughts – Part 2

By | Events, Focus Area Roundtable, Resources | No Comments

The Transparency in Coverage Mandate and the No Surprises Act are forcing health plans, health systems, healthcare providers to focus their attention and already overburdened resources on price transparency compliance-related activities. While price transparency mandates and regulations are intended to help make healthcare better and more cost-effective for health plan members and healthcare provider’s patients, there are strategic and tactical reasons to holistically address the following aspects of price transparency:

  • Policies, Programs, & Tools
  • Data Standards, Data Collection & Operational Considerations
  • Increasing End-User Adoption
  • End-user Education & Support
  • Payer-Provider Relationships

In the first post of a two-part series, Healthcare Price Transparency – Leaders Share Insight – Part 1, highlights from our first Focus Area Roundtable on Costs & Transparency held on April 5, 2021 were shared. HCEG members working for health plans, healthcare providers, and healthcare-related technology/service organizations shared their responses to some questions presented by Andy Hoffman and Matt Parker, two thought leaders with our 2021 Focus Area Partner for Costs & Transparency: HealthSparq.

Stakeholder Adoption, End-User Support, & Payer-Provider Relationships

In this second post, comments and insights from Focus Area Roundtable participants on the following aspects of price transparency are presented:

  1. Increasing stakeholder adoption of price transparency tools and services
  2. The importance of end-user education and support
  3. Payer-provider relationships to support access to price transparency information

RELATED: Understanding the Transparency in Coverage Mandate

Increasing Stakeholder Adoption of Price Transparency Tools

I think the concept of just being a liaison will go a long way on either side through this process. (Health Plan)

Go into the prescriber’s workflow with price transparency, going to the physician’s workflow with pricing information that not only saves the system money but that directly affects the consumer in a way that is frictionless. (Industry Analyst)

Whenever these conversations come up, taking a step back and saying [asking] Who’s going to benefit the most? And by that, I mean not just like the individual or the entity but the health system at large. If it doesn’t really waterfall to the whole cost of care and care opportunities, then we’re probably just clogging up the system. Who’s this going to piss off? Who’s going to lose from that deal? Companies taking rebates are going to lose. Companies overcharging and hiding pricing are going to lose. Intermediaries who aren’t necessary may lose. (Industry Analyst)

We’ve kind of assumed that we have to have all of these systems connected and all this interoperability wired in order to do that. But I’ve seen some really successful approaches and getting information into the decision maker’s hands that benefits the end consumer of health. (Industry Analyst)

Take something like hip and knee replacements. There’s an awareness of ambulatory participation, acute participation, post-acute participation on a couple of levels whether that’s brick and mortar and or home on the post-acute side. (Technology Provider)HCEG Focus Area Roundtable. Costs & Price Transparency. Compliance Regulations Mandates. Policies, programs, and tools. Data standards. Operational considerations. Increasing adoption. End-user education and support. Payer-provider relationships.

Health Plan, Health System, & Healthcare Provider Leaders – Click on the Above to Join a Focus Area Roundtable

Importance of End-User Education and Support for Price Transparency

Price transparency has different meanings to different people depending on their roles and expectations. (Provider)

I think hospitals will have to somehow educate patients and that can come in different forms. And whether it’s on a one-on-one setting or more about broader communication, there is an element of patient education that will need to happen. It’s going to be a lot more complex because it’s going to also have to account for the impact of the health plan. So, the education component is going to be large. (Industry Analyst)

I think the reality is most of us don’t really want to solve the problem in terms of us being the recipient of care. So, if I’m a patient, member, consumer, employee, I want the system to fix these things. I want my health plan that I signed up for to be smart. I want my doctor to have information and just do stuff that doesn’t cost me excess money. I want my pharmacist. (Industry Analyst)

We’re in rural areas so that’s a big, big challenge for us. But what does it mean to the consumer? Do they think that when they go in and try this tool that they’re going to understand precisely what the cost of their knee surgery is? And then is it going to be a big dissatisfier when they learned that surgeon had to do something more, or it was more complex than they originally thought? And as a result of that, they disengage. So, will this help or harm them? (Health Plan)

And then there’s the component of things that even an educated consumer might not know about like the anesthesiologist in the acute setting which rarely gets talked about. And then a bill shows up, let alone the medications that are incurred post-acute. (Technology Provider)

We also have a couple, sort of, denominators there. Am I able to figure this out on my own? Do I have search skills? And EOB skills? And ICD-10 code skills? And then the other is: Am I on Medicaid or sort of a capped model where what do I care about the price? (Industry Analyst)

Patient-Physician Relationships May Offset Price Transparency Benefits

I think it’s a personal thing. For surgeries you develop a relationship with your physicians so even if you see a great price somewhere else, I don’t think that people would jump out to go have say like a knee replacement or shoulder replacement or something even more critical with another physician somewhere else. (Provider)

If they have a relation, they tend to sort of stick with what they know. The people that would make the change are not the people that we would see price making the decision from a true consumer choice perspective but those that are just utterly desperate and have, maybe require something that they can’t otherwise get at which is, again, not part of, not really the spirit of the law, per se. (Health Plan/Provider)

RELATED: Healthcare Leaders Focus on Healthcare Policy & ACA

Payer-Provider Relationships Impacts from Price Transparency Compliance

How do you see the relationship between payers and providers in the space of both informing about price transparency but also making sure that the messaging is consistent? Because again, your got contract disputes and a lot of the No Surprise Act is going to come around contract disputes. (Technology Provider)

This [price transparency] could change the relationship between the provider and the payer. And we’re already seeing a lot of movement around mergers and acquisitions and perhaps this would incent that kind of behaviors further – or maybe not. But I think there will be some sort of macro-level impact as this becomes more widespread. (Health Plan)

Well, I think when it comes to that relationship of payer and provider, one key element that’s going to go a long way actually is support. And support probably more for the hospital side because there’s an element of an IT integration of the back end that you have to think about. And how does it all fit together? And what codes they have to integrate through? (Thought Leader)

Join a Focus Area Roundtable – Connect with Healthcare Peers

Additional Focus Area Roundtables on Costs & Transparency – and other 2021 HCEG Top 10+ focus areas such as Healthcare Policy & ACA, Interoperability, and M & A /Joint Ventures, among others – will take place throughout 2021. If you are interested in participating, reach out to us via email or complete this short form to indicate your interests.

To receive recaps of our Focus Area Roundtables and other information of potential use for leaders of health plans, health systems, and healthcare provider organizations, join our newsletter.

Healthcare Price Transparency Price Transparency Regulations & Compliance, Policies, Programs, & Tools, Data Standards & Operational Considerations

Healthcare Price Transparency – Leaders Share Insight – Part 1

By | Events, Focus Area Roundtable, Resources | 3 Comments

Healthcare price transparency has a lot of attention and focus right now, especially in the mandate-driven space. But addressing price transparency via compliance with regulations is just a portion of what health plans and healthcare provider organizations should be focusing on to help make healthcare better and more cost-effective for their members and patients.

In our first Focus Area Roundtable on Costs & Transparency held April 5, 2021, a group of HCEG members working for health plans, healthcare providers, and healthcare-related technology/service organizations gathered to discuss some of the challenges, issues, and opportunities associated with addressing price transparency.

Challenges, Issues, & Opportunities Beyond Price Transparency Regulations

Andy Hoffman and Matt Parker, two thought leaders with our Focus Area Partner HealthSparq, shared a timeline overview of the Transparency in Coverage Mandate and the No Surprises Act and facilitated the following questions:

  • How are you thinking about price transparency within a rather heavily regulated space?
  • What do you see as key issues and risks in the price transparency space? What’s the role of the 80/20 rule?Healthcare Price Transparency Regulations & Compliance, Policies, Programs, & Tools, Data Standards & Operational Considerations
  • How can we really focus on what health plan members and provider patients need to make good health care decisions, knowing that members and patients often have to navigate in antagonistic payer-provider environments?
  • How can we balance supporting patient needs and operate as an ongoing business while also informing people what things are going to cost before they have to spend unlimited amounts of money?
  • What unique challenges or strategies are you thinking about with respect to price transparency? And what opportunities are you looking to take advantage of regarding price transparency?

This post shares insight and information shared by roundtable participants on the above questions pertaining to the following categories:

  1. Regulations and compliance including their importance and value to various stakeholders
  2. Price transparency policies, programs, and tools
  3. Data standards and operational considerations to advance price transparency

A second post highlighting participant responses pertaining to the following categories will be shared shortly:

  1. Increasing adoption and the importance of end-user education and support
  2. Payer-provider relationships to support access to price transparency information
  3. Advancing healthcare price transparency and next steps

RELATED: Healthcare Leaders Focus on Healthcare Policy & ACA

Thoughts on Price Transparency Regulations & Compliance

As a payer and provider, I can look at other hospitals across the state and they’re not even using our latest pricing. They’re just putting something out there to meet the requirement. So, if there’s not consistency in the data, it doesn’t actually help anybody. It just creates profound confusion. (Health Plan/Provider)

Some of the things that I hear my peers talk about is: Are we just solving certain regulatory requirements or are we solving something members think they want but won’t actually be able to use in an effective way?  Or are we on a road to something that will be of value to all the parties involved? (Health Plan)

So, what are the different things people are putting out there? How do we then know this is the best? This is what we should be doing versus this is what we are doing. Because I think everybody is just trying to meet the intent of the law or the letter of the law, but a lot of people don’t know how. And so, I think that’s one of the things that we’ve got to [consider] if there’s anything we can do. (Technology/Service Provider)

These are people who are sick and injured and hurt and need health care. And we’ve got to do our part to help them out and we can do that in a way that drives our overall business priorities. This sets the floor. We talk about these mandates being a floor and you build an experience on top of that that supports your member needs and supports your patient’s needs. (Technology/Service Provider)

So, I think it’s a good thing that the conversation has started. But I think that the end product is going to be significantly different from what it is that we’re looking at this point. (Health Plan)

I feel like the price transparency is just a way to get our prices out there – for the most part as individuals [procedures]. Unless it’s very comparative in descriptions, information is really hard to compare apples to apples between hospitals. (Provider)

Healthcare Price Transparency Policies, Programs & Tools

Whenever I used to roll out tools and or guidance, probably two decades ago and in more than one state, you have to understand the nature of what it is that your end goal is. And sort of work backward from that. But just sort of putting some things out there, you end up getting exactly what you put into it. (Health Plan/Provider)

For a lot of these hospitals, putting out their prices shows major vulnerabilities for them when it comes to inappropriate pricing, when it comes to the contracts that they’re having. It does highlight the contracts that they have with their different vendors. (Technology/Service Provider)

I think some plans are in sort of this game of chicken to some extent because the No Surprises Act isn’t finalized yet. (Technology/Service Provider)

And how can we give voice to that as part of the overall conversation with the administration because I think they’re trying but they’re sort of missing the point. So, I think it’s incumbent upon us as an industry to start to respond back on all of those fronts as to how best to rethink how to do that since it started out previously and it’s been through lots of different iterations. But that lack of standards or consistency is just…(Health Plan)

Price Transparency Data Standards & Operational Considerations

From the payer or provider perspective, without somewhat more explicit data structure guidance across the board, it’s [price transparency mandate] not helpful. (Health Plan/Provider)

We need a standardization so that everybody can follow that. (Provider)

I don’t think you can do comparisons. It’s not the latest data. It’s not even the same from hospital to hospital. It’s kind of all over the place. (Health Plan/Provider)

So as an industry, I think whether that’s vendor-specific or provider, payer, or even consumer, I think I’d like to see a conversation around how do we drive to those data standards? (Health Plan/Provider)

I would agree that the majority of people and hospitals are doing that [trying to comply in good faith.] They don’t collect the data internally in ways that’s terribly helpful. So, to publish it [price transparency information] requires an infrastructure that frankly many of them don’t have in a way that makes it useful as say maybe a payer would. (Health Plan/Provider)

Healthcare is local, that’s very much true. So that’ll impact the dynamics and the impact of what price transparency brings to the table. (Thought Leader)

There are operational challenges that we have to address and plan to address to be compliant with the new regulations that the question becomes: How will this look and feel to the consumer because pricing can vary so significantly? (Health Plan)

One of the challenges that we see when we engage with plans is: Who are the folks and entities within the organization that are trying to solve this problem? We’ve got to get fee schedules from your contracting folks, and you need member eligibility and claims verification. You had to pull all these different systems together and that’s been one of the things we’ve seen as a big challenge – especially with bigger payers, these big vast entities that have to solve these problems with groups that really hardly ever talk to each other. (Technology/Service Provider)

Join a Focus Area Roundtable – Connect with Healthcare Peers

Additional Focus Area Roundtables on Costs & Transparency – and other 2021 HCEG Top 10+ focus areas such as Healthcare Policy & ACA, Interoperability, and M & A /Joint Ventures, among others – will take place throughout 2021. If you are interested in participating, reach out to us via email or complete this short form to indicate your interests.

To receive recaps of our Focus Area Roundtables and other information of potential use for leaders of health plans, health systems, and healthcare provider organizations, join our newsletter.