PAYER INTEROPERABILITY: THE HEALTHCARE INDUSTRY'S LEAP FORWARD ON JULY 1
by John G. Baresky on 06/29/21
A new era of medicine is days away
Effective July 1st, patients, many healthcare provider organizations and payers will enter a new age of information sharing as the CMS Interoperabilty and Patient Access Final Rule takes effect.
It represents new opportunities and challenges that will reshape the healthcare industry for years to come.
A wide array of healthcare programs are impacted by the new interoperability requirements
CMS is requiring these payers/programs to align with their new standards:
- Children’s Health Insurance Plans (CHIP)
- Medicaid
- Medicare
The exceptions to these are:
- Free-standing pharmacy benefit programs
- Medicare cost plans
- Program of All-Inclusive Care for the Elderly (PACE)
Specific plans featured on federally exchanges for dental care
and small business health options program exchanges.
Information sharing is an integral element of healthcare
Patient care is built on the collection of information used in
order to make informed decisions. Seven important considerations:
- Patients and consumers should have access to this information so they better understand their personal well-being and make informed healthcare decisions
- As the use of technology grows in healthcare, the volume of information gathered through various means is greater than ever
- Based on advancements in medicine, the types of information collected grows diversity and complexity
- Electronic health record (EHR) platforms proficiently have become vastly sophisticated in how they collect, organize and retain patient data
- The enormous quantities of data compiled requires significant protection for privacy and security
- Enhanced information sharing can help patients, providers and payers better orchestrate acute and chronic healthcare issues that will lead to better outcomes at less cost
- As medicine and technology advance, the standards and processes involved will change as well
Healthcare interoperability rules of the road
The access, sharing, retention and sharing of this information will be aptly supported via technology means that will continue to improve its performance. However, how it is used and by who will need to be continually realigned and maintained to prevent embarrassment, abuse, fraud and waste.
Universal understanding about interoperability concepts, standards and benefits is the next challenge
Organized digital platforms retaining care and cost data are a tremendous resource for clinicians and payers to optimize care and streamline reimbursement processes. Each stakeholder understands the benefits and challenges involved with the new interoperability requirements.
It is anticipated commercial healthcare insurance through managed care plans (conventional medical and pharmacy benefit plans through employers, unions, etc.) will soon follow suit with their own forms of interoperability standards and consumer - patient access.
Moving forward, consumer and patient education is paramount
A new emphasis on the awareness and education of consumers and patients about healthcare interoperability is imperative. They need to understand how its processes function and how it impacts them from a care and cost standpoint.
A more assertive and strategic focus needs to be applied by provider organizations and payers (commercial and government) to accomplish this.
Numerous elements come into play for consumers and patients and healthcare interoperability:
- Many rural and remote areas of the U.S. do not have reliable Internet access and this includes mobile
- The term "healthcare interoperability" will be lost to many and how it benefits them will be an even further reach
- Health literacy is another mainstay issue; consumers and patients need to have a certain degree of knowledge or where to access support so that they can comprehend their own healthcare data
- The importance of privacy and security when it comes to healthcare records must be fully understood
- Consumers and patient must have knowledge of how and when to use their healthcare data and/or ask questions it
July 1, 2021 is the first step in an upcoming series of events that will establish healthcare interoperability as a new and evolving standard in the healthcare industry.
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