My friends and family do not quite understand what I do for a living. When I talk about sharing data between payers, providers, and patients, many of them say, "Why would I do that?" or "No way! I do not want my health information shared." The same thing happens when I describe a future where one can manage their health care from a smartphone or digital device. When I talk about knowing how much our medical procedure will cost us beforehand and being able to choose more affordable care before we find ourselves facing high out-of-pocket medical bills, they nod, but I can tell I am starting to lose them. If I mention APIs, USCDI, or any other acronyms health data people share every day, I have lost them completely.
When I talk about a healthcare system that puts the patient in the center, their eyes brighten. When I mention that they will not get hit with surprise medical bills or have to keep completing the same forms every time they visit their physician, they say "Thank God" or something to that effect.
The gap between "Why would I want that?" and "Thank God!" is an uncomfortable place. It's where the digital transformation of the industry is right now. We have the technology necessary to drive this transformation, but it is not enough. We need to complement technology with consistent processes and communication if we want consumers to get what they need.
A good example is the Patient Access API that payers were required to have in place on July 1. This handy "valve", if opened by the patient, will provide them with most of the data the health plan has about them. We have heard reports from several sources that folks have not yet shown up to use the Patient Access APIs. Already, payers are discouraged and starting to see their current mandated options as failures, making them less likely to pour additional resources into API adoption beyond the absolute minimum required for compliance. It is a vicious cycle that feeds on itself, so how do we break it?
One step is to support the developers of applications that connect patients to these APIs. Currently, app developers cannot easily work with payers' Patient Access APIs because those APIs lack the consistency and standardization required. Supporting large numbers of payers is impossible as each payer has implemented their FHIR APIs slightly differently, with differing registration and other processes and differing documentation for developers.
People do not think in terms of APIs. People think in terms of wanting to accomplish something specific related to their health. The data acquired via the Patient Access APIs are part of the underlying plumbing needed to make that happen. Telling patients that they have access to APIs is not helpful, but apps will drive adoption if they can access data from every payer in an easy, automated, and standard way.
Next time somebody asks me what I do for a living, I am going to say I am working with others to make healthcare more accessible. I like that answer, and I think they will like it too.
Denny Brennan, Executive Director
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Meetings this month:
Want to learn more about any of these meetings? Email firstname.lastname@example.org
Join us for our upcoming webinars:
Granular Data Segmentation to Protect Privacy and Promote Equitable Interoperability presented by Hannah Galvin of Cambridge Health Alliance on August 17, from 11-1pm.
CMS Interoperability Updates presented by Alex Mugge of CMS on August 24, from 1-2:30pm.
Missed any of our webinars in 2021? Click here to see what you've missed!
Interested in holding an MHDC webinar or have an interesting topic you'd like to present? Contact us at email@example.com
Electronic Prior Authorization Initiative
This project is a prototype implementation that automates prior authorization transactions using the industry standard, open platform methods developed by the HL7 DaVinci Prior Authorization workgroup. This project will be compliant with the three related implementation guides which utilize open, FHIR based API exchange methods. This will allow each payer and each provider to implement a single prior authorization process and format for exchange so long as all of their exchange partners adhere to the same standards.
MHDC has received funding for the ePA project from a grant distribution from the Massachusetts eHealth Collaborative. This is an important milestone that allows us to move forward with the execution of participant agreements (we are finalizing these now) and the related implementation grants to support our participant's efforts on the project.
MHDC has also been participating in the NEHI Prior Authorization Steering Committee to explore and recommend potential improvements and/or policy changes to improve payer, provider and patient experiences around prior authorization. Aside from automation of prior authorization, this group is also considering whether prior authorization applies to at-risk or risk bearing payment arrangements among many other questions. A report of the group's findings and recommendations is forthcoming.
For more information email us at firstname.lastname@example.org.
Fee-for-service reimbursement just celebrated its 56th birthday. It has lived a long and increasingly rich life stymying numerous efforts to contain its voracious appetite for the health premium dollar. New and unprecedented changes in the healthcare economy, regulation, and technology may put fee-for-service on a very harsh diet if not kill it outright.
On July 30, 1965, President Lyndon B. Johnson signed into law legislation that established the Medicare and Medicaid programs by signing H.R. 6675 in Independence, Missouri, the home of former President Harry Truman who had tried unsuccessfully to implement federal health insurance in the 1950s. Truman was issued the first Medicare card during the ceremony. The budget for Medicare/Medicaid was approximately $10 billion and nineteen million individuals signed up the following year.
Since 1966, government-sponsored healthcare has grown to cover nearly 110 million people at an annual budget of $1.4 trillion.
Several factors have contributed to this astounding rate of growth. For one, Medicare and Medicaid have increased the number of eligible individuals. When it started, Medicare medically insured people requiring cash assistance, predominantly the elderly and the poor. Low-income families, pregnant women, people of all ages with disabilities, and people who needed long-term care were soon added to the Medicare and Medicaid rolls. For example, in 1972, Medicare was expanded to cover the disabled, people with end-stage renal disease requiring dialysis or kidney transplant, and people 65 or older who chose Medicare coverage.
Medicare and Medicaid have also increased the services they cover, including prescription drug coverage, improved hospital and skilled nursing facility benefits, mammography, and an outpatient prescription drug benefit.
By the end of 2019, total per enrollee expenses for Medicare, Medicaid, and the Children’s Health Insurance Program stood at over $12,800 per enrollee per year, a 23-fold increase.
Besides increased eligibility and coverage, much of this astounding growth is due to fee-for-service reimbursement, the payment system introduced by Medicare that reimburses hospitals and physicians for each service they provide to patients. While fee-for-service has evolved over the years from its original cost-based approach, it remains a “perverse incentive” because it pays physicians and hospitals for more, rather than better, care. It has also proven extraordinarily resistant to change. Despite testing 54 alternative reimbursement models in the last ten years through the Center for Medicaid and Medicare Innovation (CMMI), only four have been permanently allowed by the Centers for Medicare and Medicaid Services (CMS).
As we move forward from 2021, four forces are converging on fee-for-service healthcare that threaten to end it, once and for all. These interrelated forces – COVID-19, consumerism, administrative burden, and mandatory provider participation in Medicare risk contracting – will make fee-for-service too complex and costly for payers, providers, and consumers to tolerate.
The COVID-19 pandemic exposed the weaknesses of fee-for-service healthcare in profound and permanent ways. COVID-19 slammed fee-for-service providers and hospitals by shutting down in-person appointments and procedures and the revenue that accompanied them. Providers in value-based contracts fared much better as they had been ensured significant, if not full, payment for each of their patients in a value-based contract.
The pandemic also revealed enormous disparities in equitable access to healthcare among persons of color, the economically disadvantaged, and the disabled. Telemedicine brought healthcare to the patient, first by enabling audio and video teleconferencing instead of in-person visits and second, by increasing the testing and deployment of remote patient monitoring and in-home acute care delivery. Whether this “democratization” of healthcare delivery is a short-term trend remains to be seen. Telehealth has proven very popular among patients, but some providers are jettisoning telehealth services for in-person care as the pandemic subsides threatening to disenfranchise many people for whom telehealth was the only access they had to the health system.
Consumerism is an overused term, but the fact remains that buyers of healthcare (individuals, employers, and government) want more value for their premium dollar. Regulations that free health data for consumer use will power the development of applications designed for a range of health markets.
Fee-for-service also makes an improved consumer experience a costly and arduous goal for payers and providers. Real-time prior authorization is possible but maintaining the data that enable it to work is much more difficult when one is forced to bear the burden of piecework that is fee-for-service. And compliance with price transparency and no surprise billing regulations is more achievable for payers and providers with value-based contracts than with their fee-for-service arrangements.
Essential to consumerism is that the individual has complete and unfettered access to all of their health data not only to see from which provider they can get the best value, but to switch easily from those providers who do not pass muster to those providers that do. This requires the standardization of data and exchange (interoperability), a prohibition on health care organizations blocking consumer access to their information (information blocking), and a shift in ownership and management of health data from the industry to the consumer.
Administrative burden is the third force bearing down on the industry. While the burden and risks of prior authorization on patient care are enormous, payers and providers continue to disagree, as they have for years, on how it should be alleviated. When you combine prior authorization reform, payer and provider price transparency regulations, and the ban on surprise patient billing, providers and payers may make the shift to value-based care to reduce the complexity of “paving the cow paths.” When reimbursement is fixed, covers the entire cost of a patient’s care, and providers are expected to manage financial risk, many providers may move from fee-for-service contracts to value-based contracts over the next several years.
The fourth and final force is CMS’s shift (through CMMI) away from voluntary participation in low or no risk payment models to mandatory participation by physicians and hospitals in full-risk contracts. While physicians have more experience than hospitals in managing risk, that experience is in contracts with significant limits on total financial exposure and narrow quality reporting. The improvements in health data quality, standardization, and exchange will produce better contracts by enabling near real-time cost and quality reporting, improved clinical risk-adjustment for varying populations of patients, and support for more effective coordination of care.
Fifty-six years is a long time to get used to fee-for-service as the primary payment model, but profound and concurrent changes in culture, the economy, in policy, and in technology just might break the habit once and for all.
August is National Immunization Awareness Month. We've all become more aware of the importance of immunizations and vaccines over the past year, but it bears repeating. When properly taken on an approved schedule vaccines save lives. This is true for COVID-19, polio, measles, the flu, and every other type of disease we now prevent or reduce using vaccines.
While COVID vaccinations take up much of the oxygen in the room these days, remember getting other vaccines is important too. A new school year is almost upon us with its requirements for getting childhood vaccines. Older adults may be aging into pneumonia or shingles vaccines. People with specific health conditions might need hepatitis A, hepatitis B, meningitis, or other vaccines. They may also qualify for some of the vaccines normally taken by older adults at a younger age or need extra boosters for some of their childhood vaccines.
Regardless of your specific situation, take the time to check with your primary care provider to see if you're up to date with your vaccines or if you've recently qualified for new vaccines you didn't know you needed to get. As Benjamin Franklin said, "An ounce of prevention is worth a pound of cure."