How Healthcare is Rapidly Becoming More Interconnected
White paper | Mike Peresie
Senior Vice President and General Manager, Medical Network, Change Healthcare
As the Medical Network general manager, Mike is accountable for all aspects of the business, including the strategy, product investments/ innovation, operations, and growth. Mike joined Change Healthcare in 2015 and has held several roles that include leading the payer market segment, leading enterprise alliance development, and serving as the general manager of the Data Solutions business.
Prior to joining Change Healthcare, Mike spent his career working as a strategy consultant for Deloitte Consulting, supporting healthcare clients as they navigated an evolving healthcare landscape.
Mike holds a Master of Business Administration degree with honors and a concentration in health sector management from Duke University and a Bachelor of Science degree from Miami University.
We live in a world where technology is everywhere. We have smart TVs, smart homes, and smartwatches. We ask voice assistants for directions, for recipes, to make phone calls, and to look up our schedules. But where are we when it comes to technology in healthcare? Although you might not yet see it as pervasively as the technology just mentioned, healthcare is becoming more interconnected. Interoperability is the industry term, or buzzword, and it’s leading to another new phase in healthcare: transparency.
In the “old days,” you no doubt recall seeing walls of file cabinets in your doctors’ offices. Most of those are now gone, replaced by fast, efficient, and secure electronic medical records systems. Such systems are definitely a step in the right direction when it comes to adding more technology to healthcare.
But there have been problems. Disparate records systems haven’t always been able to “talk” to each other to share patient records among multiple healthcare providers.
This has often led to such frustrating situations as having to fill out new intake forms each time you’re referred to a different healthcare provider. Patient records weren’t easily transferred when changing health plans. Similarly, it wasn’t easy to verify benefits. And, because coordination of care was lacking, duplicate tests or exams were sometimes ordered.
In March 2013, an early big step was taken toward interoperability in healthcare. The CommonWell® Health Alliance was launched. CommonWell still exists today and is a partnership among top healthcare IT companies, “working together to define the future of nationwide interoperability and to help ensure health care providers and individuals have access to health information …”
John Hammergren, the now-retired chairman and CEO of McKesson Corporation, said in a press release at the time, “The formation of this alliance takes health care a step closer to broad industry interoperability. A national and trusted health information exchange will break down the information silos in health care and should dramatically improve the quality and cost effectiveness of care delivery.”
Since then, the Centers for Medicare and Medicaid Services (CMS) has implemented rules that health plans and providers must follow as ongoing steps toward more connectivity in healthcare.
The former, according to the CMS, “breaks down barriers in the nation’s health system to enable better patient access to their health information.” Enforcement began July 1, 2021. The transparency rule requires health plans (payers, in industry vernacular), upon member request, to provide price and cost-sharing information for healthcare services. Its initial requirements must be implemented by Jan. 1, 2022.
The 21st Century Cures Act and the No Surprises Act are two regulatory/government rules. The Cures Act is intended to give patients and their healthcare providers secure access to health information at no cost through application programming interfaces (APIs). In addition, it protects consumers from provider information blocking. This means that providers must respond to legitimate requests for access to electronic health information (EHI) that is in their systems. The blocking provision started April 5. The Cures Act was promulgated by the Office of the National Coordinator for Health Information Technology.
The No Surprises Act, which also takes effect Jan. 1, 2022, is set up to help protect consumers from surprise charges from out-of-network providers working within a covered facility. And it protects patients from excessive charges for emergency services. Another provision of the Act requires health plans to provide an advanced explanation of benefits (EOB) to show how services will be covered before the services are provided.
One might ask: What has been driving the rapid rise in the healthcare digital transformation? One big factor has been COVID-19. The pandemic has driven many basic healthcare services online. Data on many of the things we do and use regularly in our daily lives are available to share with a simple “click.” As such, consumers have come to expect healthcare information at their fingertips.
Along with regulators—like the CMS and the ONC— and consumers, another catalyst accelerating the drive to healthcare connectedness is employers. Consumers and employers both want greater value along with quick, easy electronic access to healthcare information and services. Highdeductible health plans place more financial burden on consumers. As a result, there are higher expectations for improved service and the ability to know in advance what healthcare services will cost. Consumers now want more ability to build and tailor their personal healthcare experiences.
Interoperability in healthcare has been growing for years. Now it’s here, and both health plans (payers) and providers will need to continue working together to help advance and improve the patient experience that underlies the interoperability concept. For consumers, safe, easy access to their healthcare information is the path to better, more informed care decisions.
The larger issue is this: Payers and providers can either do the minimum to remain compliant or embrace the opportunity to drive meaningful change and create a strategic differentiator that helps them grow their businesses.
Those that choose the first path of just being compliant will find themselves at a competitive disadvantage, reducing their value propositions for employers and members. Employers will have no choice but to look to other digital health vendors to address these challenges.
For the sake of consumers, the choice seems simple. Embracing the regulatory changes as opportunities can help to build a better member/ patient experience. Safe, easy access to healthcare information is the path to better, more informed care decisions.
NOTE: No Surprises Act: https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf - Begins on page 1576 of the final bill, H.R. 133, and cited officially as the Consolidated Appropriations Act, 2021
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