Health plans should look beyond compliance to realize benefits of interoperability

In 2021, health plans may be focused on interoperability mandates, but they should also consider building a broader strategy that will help enable better member experience.

By and Richard E. Williams | 3 minute read | December 11, 2020

Interoperability sits at the crossroads of value-based care, technology innovation and consumer demand. It is one of the key capabilities that enables organizations to deliver person-centered healthcare. Many health plans may be focused on compliance with Centers for Medicare & Medicaid Services (CMS) regulations, especially the fast-approaching deadline of January 1, 2021 for some of the interoperability requirements.1

But there’s an interoperability story for payers that extends far beyond avoiding penalties in 2021. Health plans should view the mandate as the first step on the journey to better member experience, and they should develop a holistic, standards-based data management strategy that can help position them well beyond next year.

FHIR enables new possibilities for collaboration, innovation

Interoperability is not a new goal. A long line of acronyms marks the trail of previous healthcare interoperability standards: X12, EDI, HL7, CCD, CDA, to name a few. While these standards aimed to facilitate seamless healthcare data exchange, many were good for limited use cases. But Fast Healthcare Interoperability Resources (FHIR) standard is the first to have much broader reach, bringing together all the actors across the healthcare ecosystem.

FHIR has whole communities that are driving innovation and driving toward solutions for everyday problems. For example, the DaVinci Project is a consortium of payers, providers and technology companies tackling a wide range of issues focused around payer-to-provider exchanges for value-based care initiatives. We believe these types of collaborations, with representation from multiple stakeholders and a common FHIR language, will be important to help organizations achieve true interoperability.

Interoperability: Beyond the mandate

In our experience, the question many healthcare payers are evaluating is how to view their investments in this new FHIR standard, and if their strategy takes interoperability beyond the mandate.

Healthcare payers often have legacy debt with their current information systems, where data is often difficult to access and integrate. The interoperability mandate requires investment in FHIR APIs to provide members with access to their own data within a tight timeframe. The health plans that have invested the minimum will use FHIR to solve for the mandate.

On the other end of the spectrum, there are health plans that will overhaul their entire health IT infrastructure to adopt FHIR and leverage the standard to its fullest capabilities. They will use this data as a timely way to deliver insights and re-position themselves as the orchestrator of their member’s healthcare. This same information can help healthcare payers transform other processes beyond the mandate by changing the way data flows within a health plan.

For example, to identify and close gaps in care for their members, health plans must go through a lot of effort to extract and cleanse claims data and apply quality rules. They could expedite these care management processes with FHIR APIs, which can help them reduce effort and close gaps earlier. Health plans could also provide this data to physicians to inform outreach. It is one example of how FHIR APIs can help healthcare payers be more proactive, anticipate member needs, more effectively manage risk and improve care.

Empowered consumers will change the health plan business model

Interoperability can help organizations give people greater transparency and access to their own information. It should help enable people to more effectively manage their own health and well-being, which is designed to achieve better outcomes and lower costs. Health plans must adjust their business model to better engage these increasingly empowered members.

Another area health plans will need to examine closely is consent management. As data becomes more fluid, moving at the request of members between health plans or third-party apps, patient consent must follow the data. It must govern the uses of that data, too. Comprehensive and secure consent management is essential to the health plan’s relationships with its members.

We anticipate that regulations will accelerate the industry’s progress toward true interoperability. Health plans that focus on holistic data management strategies will be better prepared to deliver the healthcare experiences members expect in 2021 and beyond.