Lack of technical preparation—from legacy technology to data silos—continues to hinder the promise of interoperability in health programs. It also creates barriers to innovation.
Before the next phase of interoperability takes effect, payers must overcome these challenges: Widespread adoption of application programming interfaces (APIs), such as Fast Healthcare Interoperability Resources (FHIR), which will enable consumers to touch their phones by touching them.
Break down the barriers of technical preparation
Six months later New interoperability rules Effective, the health plan is still difficult to achieve Develop a cohesive corporate data strategy And infrastructure. This makes it challenging to develop a single source of truth that can help identify member risks, narrow the care gap for patients with chronic diseases, and even determine the quality of care that members receive, whether virtual or in person.
In addition, many programs struggle to derive actionable insights from the data they collect.Therefore, 62% of health plan leaders said Improve artificial intelligence and machine learning capabilities and drive their adoption It is a “very important priority” for their organization.
By January 2023, the collapse of these technical preparations will become more apparent, when the Medicare and Medicaid Service Centers will begin to require some payers Implement FHIR-based API That:
- Provide patients with access to claims and encounter data as well as pending and valid prior authorization decisions
- Public provider directory
- Enable patients to request the exchange of certain clinical data with other payers
In view of the obstacles that members usually face in obtaining health information, such changes may have a significant impact on the member experience.Today, some 40% of patients You must go to the health care provider’s office or hospital to obtain a copy of the medical record or image scan. Although 66% of consumers can access the patient portal, only 18% of respondents are able to receive digital records through the portal.
Bridging the preparation gap
How does a health plan leap from an emerging state of technological readiness to a state that not only conforms to API standards, but can also use APIs to support internal workflows? There are three methods to consider.
Break internal and external data silos. Realizing the promise of medical interoperability requires all key stakeholders to have access to connected data. However, even in health plans, data islands between departments are not uncommon.For example, between data islands Pharmacy and medical benefit management Limit the ability of health plans to fully understand the cost drivers of specific populations.When health plans integrate data from these departments, the impact on health outcomes and costs is huge: a health plan achieves fewer emergency room visits, lower hospitalization rates, and higher member participation in the care management plan Monthly fee reduction per member by US$117 Through the integration of pharmacies and medical benefit plans.
The leaders of the Appalachian Health Program have found that by ensuring that performance is tracked in one place, the organization can more effectively improve the star rating performance under Medicare Advantage. This means eliminating silos of information so that team members can use data analysis more effectively to identify key gaps in care and jointly determine strategies for improvement. A customized dashboard tracks planned work. Influence? It became one of 110 Medicare Advantage plans to receive 4-star status in 2021.
The development of safe and accurate master data sets for patients and providers is critical to breaking data silos. Through continuous governance, master data management technologies can achieve interoperability faster. In addition, the use of standards to rationalize and manage patient clinical data can enable semantic transformation of clinical data between providers and drive value in AI use cases that require rich data sets.
Harness the power of cloud-based analyticsMore and more health plans are using cloud computing to understand different data types—from the social determinants of health data to medical records, pharmacy, and laboratory information—to gain a longitudinal view of members. Relying on cloud-based analysis, health plans can access artificial intelligence and machine learning software through the cloud platform to overcome the analytical challenges associated with traditional technologies. This eliminates the challenges associated with fragmented and isolated data. It also provides a more detailed understanding of the action steps required to improve results and reduce risk.
one Industry survey It shows that 78% of healthcare organizations have integrated cloud computing into their operations, and another 20% plan to invest in cloud computing. at the same time, Nearly half of the health plan leaders were surveyed Said that their organization has a dedicated artificial intelligence and machine learning innovation laboratory to support enterprise-wide adoption.
Smaller health plans can leverage the cloud provider’s infrastructure and applications through a platform-as-a-service model to migrate to the cloud.
Strengthen the ability to prevent fraud, waste and abuse. Although some industry groups are concerned about the new interoperability rules Put patient privacy at risk, Such concerns should not become an obstacle to innovation.On the contrary, due to the pandemic, the health insurance industry is facing increasing risks of cybersecurity threats. The Fitch Ratings report stated Significant increase in insurance claims Related to ransomware attacks, health plans should double their cyber security defenses.One suggestion is Implement a zero trust security model This requires all users to be authenticated, authorized, and continuously verified before accessing the health plan’s applications and data.
82% of health plans also Create rules and scoring According to a survey, it automatically detects potential fraudulent schemes. These include the development of logic-based rules for specific types of claims, as well as user-defined rules that use specific program codes and modifiers to actively mark claims for review. Some programs choose to apply rules and scoring to specific groups of people, such as Medicaid-managed care.
Leading health plans rely on artificial intelligence to detect suspicious activities, such as impossible one-day billing and simple encounters that are coded into seemingly more complicated situations. Although only 12% of the health plans surveyed took this action, 83% Plan to invest in artificial intelligence Used to prevent fraud, waste and abuse.
Ways to invest in the future
Although interoperability is a driving factor in the adoption of digital health between health plans, organizations must strengthen their technical preparation for extensive data sharing and analysis to lay a solid foundation for transformation. Backed by strong internal collaboration and commitment to innovation, developing a cohesive strategy for data capture, analysis, and protection is a good starting point.
Photo: Bowner, Getty Images
