How CMS’s interoperability mandate drives healthcare cost reduction and enhances member experience

The landscape of healthcare is rapidly evolving, and health plans find themselves at the intersection of digital transformation and improved member experiences. Central to this transformation is the concept of data interoperability, a catalyst that is paving the way for seamless virtual and in-person care. At the heart of this shift lies the Centers for Medicare & Medicaid Services’ (CMS) Interoperability and Patient Access Rule, a regulation that plays a pivotal role in expediting this digital revolution.

As of July 1, health plans are mandated to provide patients access to their data through a Fast Healthcare Interoperability Resources-based API, a significant extension from the initial deadline of January 1, which was delayed due to the COVID-19 pandemic. This rule applies not only to Medicare Advantage plans but also to state Medicaid and Children’s Health Insurance Program (CHIP) agencies, along with insurers offering qualified health plans or Medicaid and CHIP managed care plans. Additionally, starting January 1, 2022, payer-to-payer data exchange based on the United States Core Data for Interoperability standards becomes compulsory.

Rather than viewing the interoperability mandate as a mere compliance requirement, health plans should recognize it as a strategic opportunity to gain a competitive edge. Modern consumers now demand sophisticated, omnichannel digital experiences in healthcare, akin to what they expect from industries like banking, retail, and entertainment. The CMS’s Interoperability Rule equips health plans with the real-time data sources needed to not only reduce overall healthcare costs but also significantly enhance member experiences.

Here are the key benefits health plans can derive from embracing the interoperability mandate:

1. Cost Efficiency: By leveraging health plan consulting, administrative costs can be substantially reduced. Manual processes embedded in quality metrics reporting can be eliminated, and integrated medical claims, clinical, pharmacy, dental, and consumer data can be evaluated alongside socio-economic and social determinants of health. This comprehensive approach not only improves health outcomes but also trims down care costs significantly. Health plans can share valuable data and insights with members, promoting medication adherence and better chronic disease management, thereby maximizing their return on investment.
2. Optimized Care Delivery: Integrating clinical data longitudinally provides a holistic view of member medical consultations and treatments. This comprehensive perspective enables clinicians to predict patient needs accurately and empowers health plans to align their services with their members’ medical and financial requirements. By embracing digital technologies in virtual and in-person care settings, health plans can optimize care delivery, ensuring efficiency and quality. Importantly, data ownership remains firmly with the members, enhancing trust and transparency in the healthcare journey.
3. Omnichannel Member Experience: Health plans can create a hyper-personalized member experience by leveraging the interoperability mandate to eliminate data silos. Integrated, interoperable data offers valuable insights that, when combined with the right communication channels, content, and cadence, can create an orchestrated, omnichannel member experience. This tailored approach enhances member satisfaction and engagement, crucial factors in the modern healthcare landscape.
4. Improved Risk Stratification: Traditional risk stratification methods often rely on subjective member responses, leading to incomplete health histories. In contrast, the CMS’s Interoperability Rule mandates the availability of six years’ worth of data for each member. By obtaining member consent to leverage this data, health plans can significantly enhance their actuarial and underwriting processes, ensuring accurate and complete diagnosis and risk score coding. This accuracy is paramount, especially for Medicare Advantage plans and arrangements based on risk-adjusted metrics, ensuring the success of these programs.
5. Enhanced ROI from Population Health Management and Value-Based Care Initiatives: While the Interoperability Rule does not mandate specific population health management (PHM) or value-based care capabilities, proactive health plans are using interoperability data to identify care gaps, enhance decision-making, improve member outcomes, and reduce costs. Leading health plans are integrating their PHM systems with interoperability, leveraging advanced analytics to craft personalized care plans for high-risk, chronically ill members. The intersection of digital healthcare consulting and interoperability offers unprecedented potential, allowing firms to thrive in the evolving healthcare industry landscape.

In essence, the CMS’s Interoperability Rule is not just a compliance measure—it is a gateway to an array of opportunities for creating substantial value across the health plan landscape. Health plan leaders who fully embrace these opportunities stand to benefit their members and their organizations, ensuring not only compliance but also enduring success in the dynamic healthcare sector.