In a recent webinar, Kendra Obrist, a Senior Consultant with Point of Care Partners (POCP), shared a framework she uses to categorize the way organizations approach regulatory compliance. She groups them into one of four buckets:
- Box Checker
- Cautious Follower
- Strategic Positioner
- Leader and Innovator
That last group is one that Obrist knows well. Her employer, POCP, supplies the program management for the HL7 Da Vinci Project, a multi-stakeholder collaborative to support the information sharing needed for value-based care. Which means that POCP works with many of the most innovative payer, provider, and vendor organizations in US healthcare. Those are the organizations paving the way for everyone else, and the US Center for Medicare and Medicaid Services (CMS) is so confident in their work that it has been enshrined in recent regulations.
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requires that “impacted payers” deploy technology and numerous operational changes to facilitate information sharing and streamline prior authorization processes. The impacted payers are basically those federally funded plans operating under managed care models, for example, Medicare Advantage plans.
Interestingly, the rule requires the use of HL7 FHIR Application Programming Interfaces (APIs) but avoids most of the specifics, instead strongly encouraging payers to adopt the Implementation Guides (IGs) developed by the Da Vinci project and piloted by its members – the leaders and innovators.
Jeff Rivkin, Research Director for Payer IT Strategies at analyst firm IDC, points out that many payers continue to take a one-year, tactical approach to each regulatory mandate project. In other words, they are Kendra’s box checkers. He goes on to suggest that in order to “ensure operational excellence for members, providers, and internal constituents, payers instead need to evaluate individual mandates in the context of an overall vision.”
I have my own slightly different set of buckets inspired by Kendra, Jeff, and our experience with the CMS Interoperability and Patient Access rule (CMS-9115-F), an earlier mandate:
- Check the box
- Modernize incrementally
- Invest strategically
The earlier rule put in place a foundation on which to build. It required that claims and clinical data held by the payer be shared with members using FHIR APIs. And it established a rudimentary process for payer-to-payer information sharing. We spoke with plenty of “check the box” organizations. But most of the ones that went on to partner with InterSystems were those that saw the inherent value of integrating clinical and claims data as a strategic information asset. IDC refers to this as a “Member-360” record.
A Member-360 record allows customer service, enrollment, claims, and care coordination teams to access and use the same information base to profile members and provide the level of service members require in today's consumerization of healthcare and health insurance. But to achieve these goals effectively, the implementation strategies used by a payer for regulatory mandates also need to optimize this data asset.
Rivkin recommends developing a long-term architectural vision that includes compliance with regulatory mandates. This approach accommodates both my second and third buckets. One might, for example, deploy a Member-360 longitudinal health record to support the three “access APIs” mandated by the new CMS rule, but plan for a full-blown modernization of prior authorization in a second phase of that vision.
Regardless of which bucket your organization falls into, you’ll need a partner to help you meet both your immediate, and long-term compliance and information management goals. Consider:
- Current CMS mandates depend heavily on the work of the Da Vinci project and require deep knowledge of HL7 FHIR. You need a partner with experience in both.
- New rules for payer-to-payer information sharing require payers to integrate the data they receive – including clinical data - with other data they hold. Gartner states that: “Healthcare payer CIOs and executives routinely underestimate the complexities involved in clinical data integration initiatives, leading to subpar business outcomes.” Does your proposed partner have the specialized expertise to assist you with this complex effort?
- As information sharing gains traction, data volumes are expected to grow dramatically. Can your proposed partner deliver consistently at scale and have they proved this over time at multiple organizations?
- Does your proposed partner have a path forward for you, regardless of where you are starting from? And does that path go beyond mere regulatory compliance? For example, to helping you manage complex provider network data? Or to deliver digital front door services and robust identity management for multi-source data?
Even if your organization is already stretched too far to take on one more thing beyond the bare minimum of “checking the box,” you can achieve regulatory compliance in the context of an overall vision for the long term. And for 0057, we all get to benefit from the leaders and innovators helping to make that vision a reality through the Da Vinci Project.