Policy & Regulation News

Interoperability Reform Should Boost Claims Data Access, AMGA Says

Interoperability reform rules recently proposed by CMS and ONC should promote claims data access through APIs to advance value-based care, the organization advised.

Healthcare interoperability and claims data access

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By Jacqueline LaPointe

- Increased claims data access for providers should be at the heart of new interoperability standards and requirements, AMGA recently stressed in comment letters on two proposed rules from CMS and the Office of the National Coordinator for Health Information Technology (ONC).

The organization otherwise known as the American Medical Group Association advised the agencies to use application program interfaces (APIs) to bolster claims data access and ensure providers have the information they need to deliver value-based care.

“Sometimes we forget that the power of information technology is as a tool providers can use to better treat patients,” Jerry Penso, MD, MBA, AMGA president and CEO said in a press release. “Standards and interoperability are important and should not be overlooked, but we can’t lose sight of the why we use such systems. And that’s to ensure our care teams have all the information necessary to provide patients the best care and practices have the data needed to develop population health strategies.”

Interoperability promises to get providers the information they need, but Penso explained that health IT systems “are only as strong as the data they transmit, which is why we need real-time claims data.”

Lack of administrative claims data access continues to be the most significant challenge of moving to value-based care and risk-based arrangements, AMGA recently found in its fourth annual risk survey. Without robust claims data access, providers are struggling to track patients throughout their journey and develop the population health management capabilities necessary for value-based care success.

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Both CMS and ONC are dedicated to moving the industry toward value, and the agencies can advance the transition away from fee-for-service through their proposed interoperability rules, AMGA explained.

For example, the agencies can require payers to share all administrative claims data with providers via APIs.

“Sharing claims data through an API ensure providers have full access to a patient’s medical history, which enables providers to ensure their patients are receiving the most appropriate care. The data also informs population health efforts, which requires both access to claims data and clinical data,” the organization stated in its letter on CMS’ proposed rule (CMS-9115-P).

With access to both clinical and claims data, “providers have a powerful tool to manage the health of a population, particularly for chronic disease,” the letter added.

Requiring payers to share claims data through APIs is key, AMGA highlighted. Payers have data on the types of services and prescriptions a patient has received, which is oftentimes inaccessible to providers who are attempting to coordinate care and develop population health management strategies.

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“Sharing this data via an API would offer providers the ability to view in ‘real time’ the care a patient has received. Reviewing this data will inform provider’s care decisions and has the benefit of helping to reduce test redundancies and unnecessary procedures,” the letter stated.

In addition to claims data access, AMGA also recommended that CMS bolster health information exchange between providers and payers by making electronic admission, discharge, and transfer (ADT) notifications part of Hospital Conditions of Participation (CoP), developing a common algorithm for patient matching, and indicating on Physician Compare whether physicians engage in information blocking.

In their comment letter to the ONC on proposed implementation of provisions in the 21st Century Cures Act, AMGA cautioned the agency that its timeline for implementing a more interoperable and coordinated delivery system may be too aggressive.

While AMGA supports the advancement of interoperability, especially in the name of value-based care, the organization said that the proposed 2020 deadline may not be feasible for providers and other stakeholders to implement the complex changes needed.

“When finalizing its rule, ONC should work closely with the Centers for Medicare & Medicaid Services (CMS), which also has proposed significant changes to advance interoperability, to set feasible and achievable timeframes and deadlines for information technology vendors, payers, and providers to address the operational and technological challenges that result from the rule,” the organization advised.

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Additionally, AMGA expressed concerns about proposed healthcare price transparency requirements promulgated in the ONC’s proposed rule.

In the rule, the ONC is asking for comments on the parameters and implications of including price information in electronic health information, as well as on the technical, operational, legal, and other challenges of increasing healthcare price transparency.

AMGA commented that the ONC should look to payers for increased price transparency since patient financial responsibility largely hinges on a health plan’s benefit design.

“Providers are not the source of information regarding the individual benefit structure for patients and oftentimes do not know the financial responsibility of the patient until after the service has been provided. This information rests with payers,” AMGA wrote. “Payers should work to educate their members on the costs they may face when they receive a service. Because payers have all necessary financial data related to the patient, the focus should be placed on individual insurers to make pricing information available.”

Furthermore, ONC should be aware that pricing information is more complex in the age of value-based care. For example, prices are not straightforward for providers participating in bundled payment models or accountable care organizations (ACOs).

“Presenting patients with a list of itemized prices may be of little use in such models,” AMGA explained. “Providers may receive a bundled payment or continue to be paid on a fee-for-service basis. However, the prices charged or the eventual fees paid do not demonstrate the value inherent to the patient.”

“Providing pricing information, while important, is only one aspect of the patient experience and likely will not capture the value of care in a delivery system that is built on care coordination, prevention, and population health,” the organization added.

Healthcare interoperability and increased data transparency are vital to the success of value-based care. Providers, payers, patients, and other stakeholders need access to and the ability to seamlessly share data to inform cost-conscious, high-quality care delivery.

Through interoperability reforms and stakeholder feedback, CMS and ONC aim to make data access and exchange meaningful for all parties involved.