Health Tech

Regulation as a Catalyst for Innovation: Leveraging the Interoperability and Prior Authorization Mandate

Interoperability mandates from the Centers for Medicare and Medicaid Services (CMS) have required major investments by health plans in recent years and will continue to be critical in informing overall organizational strategies for 2024 and beyond. The looming deadlines of CMS-0057-F, the Interoperability and Prior Authorization Final Rule, will have an impact on both objectives and resources. 

At the HIMSS Global Health Conference & Exhibition in March 2024, InterSystems brought together subject-matter experts with diverse perspectives to weigh in on strategies to meet federal regulatory mandates. One of those experts was Dominick Bizzarro, Chief Strategy Officer, MVP Health Care and Executive Advisor at Innovators Within.


Bizzarro recommends employing the concepts of Agile Development to the strategic planning process, recognizing that no matter how well researched and deeply informed a 5–10-year strategic plan may be, the reality on the ground will never match what was planned for. An agile approach lets an organization set its overall direction, informed by a variety of factors, including regulatory trends, and then iterate and adjust continuously in the context of an overall vision.


Five Key Considerations to Harness Innovation through Regulation

When faced with new regulations and timelines, Bizzarro recommends approaching implementation and compliance from an innovation mindset, and thinking through five key questions:

  1. Does this align with our why?
    Your why is the purpose of your organization and what you’re trying to achieve. Do these regulations align with your why? For payers, compliance can lead to expanded data access and modernized systems that can improve and amplify your efforts.
  2. Is it inevitable?
    Are some requirements really just a matter of time? If you are reasonably certain that future regulations or expansions are likely to happen, it may be wise to get ahead of those timelines and build comprehensive approaches. If you know that something is highly likely to be inevitable in the future, you can develop a competitive advantage by building and expanding your approach today.
  3. Are there synergies with other projects we have going on in the organization?
    What are your other strategic priorities in the organization? How can you leverage your compliance with mandates and deadlines to provide momentum to other initiatives? Finding synergies and piggybacking on existing efforts can strengthen your approach.
  4. Can we beat the timeline of the regulation?
    Are you able to shift your thinking from meeting the deadline to beating the deadline? Implementing necessary changes ahead of the deadline can potentially allow you to leverage them for strategic advantage.
  5. What is our organization’s state of readiness and resolve to get it done?
    This requires an open, honest, and vulnerable look to determine if your organization is prepared and determined to take on this challenge. While you may never be 100% ready, do you fully understand your gaps and state of readiness? Are you prepared to have the courage and resolve to move forward?

Answering these questions to guide your organization’s approach will provide you with context and clarity as you move forward toward strategies that integrate with overall strategic objectives and priorities.


Regulatory Direction for Interoperability

US federal regulatory history related to healthcare information over the past 25 years shows a clear set of trends: digitizing health data, creating a FHIR-based information sharing ecosystem to facilitate value-based care, empowering healthcare consumers, and leveraging data to reduce the burden of manual processes.

Consider these trends in light of Bizzarro’s questions, and it becomes evident that the federal interoperability mandates deserve more than a footnote in the strategic plan. For example, what does it mean to address a regulation? If you fulfill the letter of the law by the deadline, is that enough? Or is there an opportunity to take a more meaningful look at what we’re trying to accomplish? Can you move beyond checking the box to achieve strategic advantage?

What partnerships do you need to put in place to implement your vision? For interoperability, those may include regional and national health information networks as well as your provider partners. You’ll also need one or more IT vendors. Ideally these should offer you a path beyond mere technical compliance so that your information investments deliver foundational value, and your vendor becomes a trusted advisor.

As Bizzarro noted, regulation doesn’t have to be something done TO you – it can be something done FOR you. Ultimately, a successful agile strategy approach will help you leverage regulatory mandates to advance your vision.

The editorial staff had no role in this post's creation.