August 2021 Newsletter

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

Please let us know what you think of our newsletter at and look for our next issue. Thank you for your continued support and participation!

MHDC Events

Meetings this month:

  • CIO Forum: August 18, 8-10am - POSTPONED
  • DGC SDOH Deep Dive: August 5, 2-4pm
  • DGC Steering Committee: August 11, 3-4:30pm
  • DGC Working Group: August 11, 18, 25, 11am-12:30pm
  • NEHEN Business Users Group: August 5, 9-10am
  • Spotlight Users Group: August 31, 2-3pm
  • Webinar: Cambridge Health Alliance: August 17, 11am-1pm
  • Webinar: CMS: August 24, 1-2:30pm

Want to learn more about any of these meetings? Email

MHDC Webinars

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

Spotlight Analytics Update

Spotlight Business Analytics helps healthcare organizations run custom analytics on health data including market share, patient origin, disease prevalence, cost of care, and comparative costs and outcomes for acute care hospitals.

We are working on incorporating new datasets in Spotlight to enhance the analytics and reporting including local and national comparison metrics. We'll have more information coming soon. Meanwhile, we're planning to hold meetings with current Spotlight users to discuss how to make Spotlight better and meet the different needs and objectives of each user. We're also holding our next Spotlight User Group Meeting on August 31 at 2pm to discuss these topics and anything else that comes up. Please join us - register here to get login details.

Our current status is:

Loaded and available for use:

  • Massachusetts Hospital Inpatient Discharge Data FY19 (HIDD)
  • Rhode Island Hospital Inpatient Discharge Data FY19
  • Massachusetts Emergency Department Discharges FY19 (ED)

Future planned data:

  • Massachusetts Outpatient and Observation FY19 (OOD)
  • Massachusetts Hospital Inpatient Discharge Data FY20 (HIDD)
  • Rhode Island Hospital Inpatient Discharge Data FY20
  • New Hampshire Facility Discharge Data Sets (Application pending)
  • Maine Hospital Inpatient and Outpatient Data

Please feel free to drop us a line with any questions or comments at In the meantime, thank you for being a Spotlight Analytics user and a member of this community! Feel free to visit our Spotlight Business Analytics page or email us at the address above for more information.

DGC Update

The Data Governance Collaborative (DGC) at MHDC is a collection of payers and providers throughout the region exploring ways to better exchange health-related data incorporating industry standards and automation as much as possible.

The DGC expects to move to the implementation phase of the code mapping service soon. This system will be available to anyone (with a discounted rate for DGC members).

We continue to participate in industry events and workgroups that help inform our work and have been looking more closely at new and upcoming regulations and laws including the No Surprises Act set for implementation starting January 1, 2022, the newly released draft of a 21st Century Cures Act 2.0 bill, and new CMS proposed regulations.

We are planning to ramp up the frequency of our Deep Dives to approximately once per month, so expect more regular updates in this space. If there's a topic you'd like to see us discuss in a future Deep Dive, please let us know at Our next Deep Dive on social determinants of health (SDOH) on Thursday August 5th from 2-4pm. We expect this to be the first of several conversations on the topic and look forward to gathering information about the current state of SDOH data within healthcare organizations. Deep Dives are free and open to the public - please join us. You can register here.

Membership in the DGC is open to any payer or provider with business in Massachusetts - big or small, general or specialist, traditional or alternative. Want to know more? Email

NEHEN Update

NEHEN reduces administrative burden through the adoption of standardized transactions. It is a cornerstone service for payer and provider trading partners wishing to exchange industry standard X12, HIPAA compliant transactions in a real-time, integrated manner using APIs. Because of our unique governance, non-profit status, and membership-based model, NEHEN is able to offer very competitively priced services relative to the market.

NEHEN has been exploring an advanced roadmap development plan from TriZetto (funded by a 2 year, $20 million investment by its parent company Cognizant). Many benefits and opportunities should accrue to users of NEHEN's services once these plans are realized. The four areas of focus in their roadmap are: patient engagement, claims management, denials, and contract management. We discussed the patient engagement advancements in July; we will discuss the other three at the next NEHEN Business User's Meeting on August 5th. If any MHDC Members would like to attend please reach out to us at the address below.

For information about NEHEN please contact us at

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

Industry Events

Interested in webinars and online conferences through July? Here are some we recommend (they're free unless otherwise noted):

We do periodically post webinars we plan to attend on social media, so feel free to follow us on Twitter (@mahealthdata) and LinkedIn for more webinar ideas and for our take on interoperability, data, health equity, telehealth, APIs, and other topics of interest.

Have an upcoming event next month to suggest? Write us at - no self-promotion please.

The History and Future of Fee-For-Service

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.

National Immunization Awareness Month

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."

Wrapping Up

Before we go, here's a reminder of upcoming data exchange deadlines from ONC and CMS (including the CMS rule that's currently frozen, as noted by *):

And that's it, folks. Loved it? Hated it? Have an idea for next time? Send us feedback and suggestions about this newsletter at or send us feedback and suggestions about anything else at

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