Why Clinical Interoperability Between Providers And Payers Is So Important

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Mother and baby daughter filling out medical form.

Bringing payers into the data-exchange loop will advance efficiency and drive better care outcomes

Clinical interoperability among providers is a long-acknowledged critical imperative for improving patient outcomes and enabling personalized care coordination. Now, with new, innovative technology available, it’s time to expand the scope of clinical-data exchange in pursuit of consumer-centric care and even greater efficiency.

The Impetus

There are numerous reasons to expand healthcare data interoperability. With the advent and growth of consumerism in our industry, patients are expecting more from providers and payers; they want easy access to their medical records and expect a seamless healthcare experience that is data driven. The Centers for Medicare and Medicaid Services and the Office of the National Coordinator agree that improved data sharing can drive better care and lower costs, and they’re pushing providers, payers, and healthcare IT vendors to remove barriers. Payers and providers, too, see the exponential potential that fluid data exchange could have on improving patient care and driving efficiency.

Benefits of a Nationwide Interoperability Network

A comprehensive network that connects payers, providers, members, and EHR systems across the country enables near-real time data sharing, which in turn:

  • Empowers Care Coordination
    True care coordination requires not only provider collaboration but provider-payer collaboration, as well. When payers are brought into the loop and have fast access to patient records, it helps accelerate decision making, ensure care gaps are closed, and, ultimately, drive improved outcomes.
  • Helps Reduce Provider Abrasion
    Nationwide interoperability enables the industry to transition clinical data retrieval from a manual-to-automated process. This remote access to data eliminates on-site visits to provider offices, saving payers tremendous time and travel expense, and saving providers the disruption and expense of allocating staff to assist in the process (reduces abrasion). The COVID-19 pandemic revealed an additional benefit of interoperability: it helps ensure payers have access to data even if office staff are working remotely and precludes in-person interaction that could place all parties at risk. Plus, when payers have near-real time access to data, they can more quickly verify that services billed were medically necessary and in compliance, leading to faster claim adjudication, and ultimately reimbursement. 
  • Enables Value-Based Care (VBC)
    Improving care quality and cost efficiency—the two tenets of VBC—has always been data dependent. Bringing VBC to its fullest potential, however, hinges on continuous, fluid, data exchange. Providers need visibility into all services and care a patient has received to avoid unnecessary duplication, and payers need transparency across care venues to monitor adherence to protocols and to enhance plan design. 
  • Simplifies Improving Quality Scores and Risk Management
    Achieving high scores on Healthcare Effectiveness Data and Information Set (HEDIS®)¹ measures and Medicare Star ratings is a top priority for health plans. In fact, one study shows that boosting a plan’s rating by one star can lead to an increase in enrollment of 8-12%, increasing total revenue by as much as 17%². Near-real time access to data helps payers with HEDIS and Stars initiatives in two ways: First, it accelerates HEDIS and Stars scoring, so payers can more quickly leverage that information to improve member care. Secondly, it makes it easier for payers to access in-depth data about the populations being served, so they can improve plan design and interventions, and better manage risk profiles.
  • Enhances the Patient/Member Experience
    Knowledge is power. When members have easy access to their medical records, they can be more informed and more fully participate in decision making. Empowering members to play an active role in their care helps drive patient compliance, satisfaction, and outcomes. 

The Next Step Toward Consumer-Centric Care

Interoperability between providers and payers is the next inevitable step in continuing to meet consumer, legislative, and industry demands and expectations, while creating a consumer-centric healthcare system.

Learn more about how Change Healthcare is driving the next level of interoperability.

1 HEDIS® is a registered trademark of NCQA
2 Bajner, Richard, et al. “The Impact of Star Ratings on Rapidly Growing Medicare Advantage Market.” Navigant, February 2018.