With CMS mandate looming, Abacus Insights rolls out interoperability solution for health plans

The global healthcare interoperability market is big business.

Frost & Sullivan projects the market to reach $8 billion by 2024, up almost 14% from $4.2 billion in 2019

Much of this growth will be driven by countries with regulated healthcare IT interoperability standards, Frost & Sullivan reported.

Here in the U.S., payers and providers are now mandated to adopt open systems to allow the exhcange of data. In March, the Trump administration finalized rule changes requiring payers, providers and hospitals to enable patients to get easier access to their digital records through smartphone apps and to facilitate data exchange by providers and health plans.

That requirement for health plans goes into effect January 1, 2021. But CMS won't enforce those requirements for an additional six months, until July 1, 2021, because of the COVID-19 pandemic.

That puts startup Abacus Insights in an ideal position as a cloud-based technology company that works with large insurers on their infrastructure. 

The company launched this week a new interoperability solution to help health plans comply with the Centers for Medicare and Medicaid Services interoperability mandate.

Abacus' secure data management and application programming interface (API) delivery platform is designed to help health plans comply with the CMS requirement and also turn volumes of patient data into valuable insights for patients, healthcare providers, researchers and digital health innovators, the company said.

RELATED: Enforcement of interoperability rules to be relaxed to ease burden on providers

While the CMS rule has put interoperability in the spotlight, the lack of effective data exchange has long been a problem for payers, according to Minal Patel, M.D., founder and CEO of Abacus Insights.

Legacy mainframe technology systems in place at many health plans have become a bottleneck. As a result, insurers, healthcare providers and patients are not benefitting from data in the way they should.

Patel founded Abacus three years ago to tackle the thorny issues of data segregation and interoperability in healthcare.

A physician by training, Patel was head of strategy at a large health insurance company and saw firsthand the data challenges plaguing health plans. While insurers amass troves of data about their members, that data often sits in disparate systems and its difficult for health plans to make use of that data to run analytics.

"We found ourselves with lots of data, but it was sitting in so many siloes that trying to get insights was very difficult," Patel told Fierce Healthcare.

Running a simple analyses of the data across different systems could take weeks to months, he said.

"This issue of data liquidity and interoperability is a structural barrier to innovation. After two years of trying to solve the problem inside the company, I recognized that this was a big enough problem not only for company I was working for but throughout the health insurance industry," Patel said.

The tackle these issues, Abacus Insights developed a platform that provides comprehensive data management, HL7 FHIR-based API delivery, a data ecosystem of connectors for onboarding diverse datasets, analytics enablement, data profiling and diagnostic reports and advanced security features, according to the company.

Healthcare interoperability is a big enough problem that Abacus Insights has attracted major investors including Blue Venture Fund, CRV, .406 Ventures, Horizon Healthcare Services Inc. and Echo Health Ventures, a strategic collaboration of Cambia Health Solutions and Mosaic Health Solutions.

RELATED: Here are 6 ways the ONC's new rules for opening health record access will impact the industry

Those investors poured $35 million into Abacus in a recent Series B funding round.

For health plans, the ability to view and responsibly make use of health data to improve healthcare is too often obscured by the silos in which the data resides, said Mike Spadafore, managing director of the Blue Venture Fund in a statement.

"Abacus Insights’ cloud-based platform connects and unlocks that data and allows patients to receive more proactive, personalized care at a lower cost," Spadafore said.

While Abacus' technology will help payers comply with the new CMS rule, the company focuses on broader use cases.

The company wants to help health plans "liberate their data" to make it shareable with patients and other stakeholders. Its solution talks to all of those disparate systems within that health plan and brings all that data into one environment, Patel said.

RELATED: CMS' new interoperability rule requires major changes for payers, hospitals. Here are 6 key elements

The Abacus CMS interoperability platform will ingest data from CMS for millions of Medicare beneficiaries, and integrate it with other data sources including medical and pharmacy claims, lab results, clinical data from electronic health records, digital and other consumer generated data.

Health plans can then use the platform to generate new insights helping consumers make better health choices and deliver more personalized health experiences, as well as enable providers to make more informed decisions by having a complete picture of the patient, the company said.

Abacus Insights also has been certified by for the CMS Qualified Entity program, also known as the Medicare Data Sharing for Performance Measurement Program.

The CMS program enables organizations that meet strict requirements for data security and privacy to receive Medicare Parts A and B medical claims data and Part D prescription event drug data for the purpose of evaluating the performance of providers, a key part of the nationwide effort to improve quality of care.

"As a Qualified Entity, we are being entrusted with data that has enormous potential for improving the quality of healthcare and outcomes for patients across the country,” Patel said.