The
CMS rule mandates that payers provide patients access to data through a Patient
Access API and access to a list of in-network providers through a Provider
Directory API.
March 09,
2020 - CMS has released the next phase of the 21st
Century Cures Act on interoperability.
The rule, which was
expected to be announced at HIMSS20 before the
conference was canceled, supports the MyHealthEData initiative, meant to enable
the flow of patient data and information among public payers.
“The days of patients
being kept in the dark are over,” said CMS Administrator Seema Verma in
the press release.
“In today’s digital
age, our health system’s data sharing capacity shouldn’t be mired in the stone
age. Unfortunately, data silos continue to fragment care, burden patients, and
providers, and drive up costs through repeat tests. Thanks to the leadership of
President Trump, these rules begin a new chapter by requiring insurance plans
to share health data with their patients in a format suitable for their phones
or other device of their choice. We are holding payers to a higher standard
while protecting patient privacy through secure access to their health
information. Patients can expect improved quality and better outcomes at a
lower cost.”
The rule states that
payers and health systems can no longer engage in “information blocking,” a
practice which restricts access to healthcare information and slows down
interoperability.
Instead, they must
provide the data through an application programming interface (API).
Third-party apps and vendors can use the Patient Access API to give patients
access to their data.
Payers must make data
available through the API so that it follows the patient from provider to
provider and payer to payer.
Third-party vendors
will require permission from the patient to access the patient’s API data, at
least for adjudicated claims, capitated providers, and payer-maintained
clinical data within one day after the request is made.
By January 1, 2021,
payers must make the data available, spanning claims from January 1, 2016
onward.
The API must meet HHS
standards, established by the ONC 21st Century Cures Act final rule.
Payers must also make
it clear which providers are in-network. This will be available through a
Provider Directory API. This must be a public-facing digital endpoint
accessible through the payer’s website.
It must be available
by January 1, 2021.
The rule outlines
seven exceptions to the rule including when
information blocking causes harm to the patient, when the information is
inaccessible due to health IT maintenance or improvements to which the user has
agreed, unfeasible requests, and other situations in which access would be
barred.
In general, ONC said
that exceptions will be determined based on whether the activity promotes
confidence in the health IT infrastructure and security, puts individuals and
entities at risk, and the exceptions are constrained to reasonable situations.
Payers have called
upon the ONC and HHS to underscore that payers are exempt from these rules.
The proposed rule
stirred up mixed opinions in the payer community. In a June 2019 letter to Donald Rucker, MD, National
Coordinator for Health Information Technology of the ONC, Matt Eyles, president
and CEO of America’s Health Insurance Plans (AHIP) supported the move towards
interoperability. However, he also listed four primary objections to the rule:
·
The challenge of maintaining
patients’ privacy if their data could be disclosed
·
Increased difficulty of keeping
patients’ data safe from security breaches
·
Anti-competitive implications of the
rule if certain pricing data was disclosed
·
The timing of the rule’s
implementation
Furthermore, as Ryan
Howells, MHP, PMP, principal at Leavitt Partners, explained in a recent Xtelligent Healthcare Media webcast, the
requirement that health plans have the ability to immediately release
healthcare information across Medicaid, the Children's Health Insurance
Program, Medicare Advantage plans, and qualified health plans will have a
significant impact on payers. It means that payers have to establish tools like
APIs and protocols to handle that kind of data sharing securely and
quickly.
From June to July
2019, Accenture surveyed 19 payer executives whose
companies each accrue over $1 billion in revenue annually to determine whether
these industry-leading payers were prepared for the new interoperability rule.
Of the 19 surveyed, 26 percent were “very familiar” with the regulations and
the same percentage characterized their companies as “very prepared.”
These numbers may
seem low, but in comparison with providers it was an impressive
representation—only 16 percent of providers said they were “very familiar” with
the proposal and a mere 5 percent felt prepared. That being said, the survey
covered three times as many billionaire provider organizations as payers.
Additionally, low
readiness among provider partners could influence payers’ shift toward
value-based care, since the payer-provider relationship is so foundational to that movement.
While the survey does
not capture the status of the payer industry as a whole, it may provide insight
into the readiness of companies with the most resources to tackle a major
technology strategy adjustment and data-sharing protocol shift.
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