By William Flood, MD, MS, chief medical officer/Eviti, NantHealth.
The COVID-19 crisis has created a perfect storm of challenges for payers as they adapt to a new normal that continues to evolve. It’s also opened up a host of opportunities for creating positive change that will enable providers and payers to run smarter businesses and provide more quality care for patients.
During a recent webinar, healthcare payers participated in interactive polling and unanimously agreed that COVID-19 has significantly changed the healthcare landscape, altering the routine day-to-day management of care and the operations that happen around it, including medical plans.
Here are some of the key aspects payers are tackling as they move forward:
Shifts in Plan Membership
The economic downturn caused by the pandemic has led to significant increases in unemployment, As healthcare coverage is frequently tied to employment, this leads to significant increase in the number of uninsured. According to a May 2020 Kaiser Family Foundation study, 45 million Americas were unemployed at that time, and it’s estimated that about 27 million are uninsured because of that loss.
While we won’t have exact numbers on how much membership has changed until open enrollment periods begin, likely in January 2021, we do know that this increase in unemployment has driven a shift from private to public plans.
It escalates the steady decline in private plans that we’ve seen for the past thirty years, putting increased pressure on government-sponsored plans like Medicare and Medicaid and providing opportunity for insurers who have not already done so to enter these markets. During a time of economic challenge, this requires reevaluation of current processes to construct more valuable and affordable approaches for stakeholders: payers, patients, and providers.
By Lisa Hebert, director of product management, NantHealth.
Our industry is stuck in an inefficient, costly trend—treating avoidable diseases rather than preventing them. According to the Centers for Disease Control and Prevention (CDC), chronic diseases, such as diabetes and heart disease, account for 75 percent of our nation’s healthcare spend. Shifting our focus to wellness will improve patient health and reduce overall healthcare costs.
How do we get there? A transition to preventative care requires value-based care that is aimed at the long-term needs of individual patients. Patient-centric and evidence-based, the model leverages vast amounts of historical healthcare data and advanced analytics to provide clearly defined routes to well-established, evidence-based treatments with proven effectiveness. It helps providers assess risks, benefits, and trade-offs of specific treatments, avoid unnecessary treatments and costs, and deliver more accurate, better quality care that keeps patients healthy throughout their lives.
Value-based care benefits all participants—healthcare providers, facilities, and plans, and the patients they serve. It’s dependent on active, ongoing participation from all parties. Collaboration is critical to its success.
Leveraging Technology to Collaborate
A value-based care system requires robust technology to replace manual tasks, reduce inefficiencies, and support the transfer of patient data in a secure, timely and comprehensive way. Done right—interoperable and seamlessly integrated with existing workflows—automation technology can enable patients, providers and payers to communicate and collaborate in meaningful ways, while saving significant costs. It is estimated that the industry could save $12.4 billion by fully adopting electronic transactions that enable them to exchange vital information in near real-time and more readily communicate and collaborate to deliver care with delay.
The Department of Health and Human Services (HHS) filed its annual year-end report to Congress at the start of 2019. The 22-page report summarized nationwide trends in health information exchange in 2018, including the adoption of EHRs and other technologies that support electronic access to patient information. The most interesting takeaway has to do with the ever-elusive healthcare interoperability.
According to the report, HHS said it heard from stakeholders about several barriers to interoperable access to health information remain, including technical, financial, trust and business practice barriers. “These barriers impede the movement of health information to where it is needed across the care continuum,” the report said. “In addition, burden arising from quality reporting, documentation, administrative, and billing requirements that prescribe how health IT systems are designed also hamper the innovative usability of health IT.”
To better understand these barriers, HHS said it conducted multiple outreach efforts to engage the clinical community and health IT stakeholders to better understand these barriers. Based on these takeaways, HHS said it plans to support, through its policies, and that the health IT community as a whole can take to accelerate progress: Focus on improving interoperability and upgrading technical capabilities of health IT, so patients can securely access, aggregate, and move their health information using their smartphones (or other devices) and healthcare providers can easily send, receive, and analyze patient data; increase transparency in data sharing practices and strengthen technical capabilities of health IT so payers can access population-level clinical data to promote economic transparency and operational efficiency to lower the cost of care and administrative costs; and prioritize improving health IT and reducing documentation burden, time inefficiencies, and hassle for health care providers, so they can focus on their patients rather than their computers.
Additionally, HHS said it plans to leverage the 21st Century Cures Act to enhance innovation and promote access and use of electronic health information. The Cures Act includes provisions that can: promote the development and use of upgraded health IT capabilities; establish transparent expectations for data sharing, including through open application programming interfaces (APIs); and improve the health IT end user experience, including by reducing administrative burden.
“Patients, healthcare providers, and payers with appropriate access to health information can use modern computing solutions (e.g., machine learning and artificial intelligence) to benefit from the data,” HHS said in its report. “Improved interoperability can strengthen market competition, result in greater quality, safety and value for patients, payers, and the healthcare system generally, and enable patients, healthcare providers, and payers to experience the promised benefits of health IT.”
Interoperability barriers include:
Technical barriers: These limit interoperability through—for example—a lack of standards development, data quality, and patient and health care provider data matching. Addressing these technical barriers by coordinating to establish the technological foundation for standardizing electronic health information and by promoting exchange of that information can considerably remove these barriers.
Financial barriers: These relate to the costs of developing, implementing, and optimizing health IT to meet frequently changing requirements of health care programs. The cost to adjust health IT to meet these requirements can impact innovation and the timeliness of technical upgrades. Specific barriers include the lack of sufficient incentives for sharing information between health care providers, the need for enhanced business models for secondary uses of data, and the current business models for health systems or health care providers that do not adequately focus on improving data quality.
Trust barriers: Legal and business incentives to keep data from moving present challenges. Health information networks and their participants often treat individuals’ electronic health information as an asset that can be restricted to obtain or maintain competitive advantage.
Elsewhere, the Center for Medical Interoperability, located in Nashville, Tenn., is an organization that is working to promote plug-and-play interoperability. The center’s members include LifePoint Hospitals, Northwestern Memorial Healthcare, Hospital Corporation of America, Cedars-Sinai Health System, Hennepin Healthcare System, Ascension Health, Community Health Systems, Scripps Health, and UNC Health Care System.
Its mission is “to achieve plug-and-play interoperability by unifying healthcare organizations to compel change, building a lab to solve shared technical challenges, and pioneering innovative research and development.” The center stressed that the “lack of plug-and-play interoperability can compromise patient safety, impact care quality and outcomes, contribute to clinician fatigue and waste billions of dollars a year.”
More interoperability barriers identified
In a separate study, “Variation in Interoperability Among U.S. Non-federal Acute Care Hospitals in 2017,” showed additional difficulty integrating information into the EHR was the most common reason reported by hospitals for not using health information received electronically from sources outside their health system. Lack of timely information, unusable formats and difficulty finding specific, relevant information also made the list, according to the 2017 American Hospital Association (AHA) Annual Survey, Information Technology Supplement.
Among the explanations health systems provided for rarely or never using patient health information received electronically from providers or sources outside their health system:
Difficult to integrate information in EHR: 55 percent (percentage of hospitals citing this reason)
Information not always available when needed (e.g. timely): 47 percent
Information not presented in a useful format: 31 percent
Information that is specific and relevant is hard to find: 20 percent
Information available and integrated into the EHR but not part of clinicians’ workflow: 16 percent
Hospitals, when asked to explain their primary inability to send information though an electronic exchange, pointed to: Difficulty locating providers’ addresses. The combined reasons, ranked in order regardless of hospital classification (small, rural, CAH or national) include:
Difficult to find providers’ addresses
Exchange partners’ EHR system lacks capability to receive data
Exchange partners we would like to send data to do not have an EHR or other electronic system to receive data
Many recipients of care summaries report that the information is not useful
Cumbersome workflow to send the information from our EHR system
The complexity of state and federal privacy and security regulations makes it difficult for us to determine whether it is permissible to electronically exchange patient health information
Lack the technical capability to electronically send patient health information to outside providers or other sources
The report also details other barriers related to exchanging patient health information, citing the 2017 AHA survey:
Greater challenges exchanging data across different vendor platforms
Paying additional costs to exchange with organizations outside our system
[Need to] develop customized interfaces in order to electronically exchange health information
“Policies aimed at addressing these barriers will be particularly important for improving interoperable exchange in health care,” the report concluded. “The 2015 Edition of the health IT certification criteria includes updated technical requirements that allow for innovation to occur around application programming interfaces (APIs) and interoperability-focused standards such that data are accessible and can be more easily exchanged. The 21st Century Cures Act of 2016 further builds upon this work to improve data sharing by calling for the development of open APIs and a Trusted Exchange Framework and Common Agreement. These efforts, along with many others, should further improvements in interoperability.”
What healthcare leaders are saying about interoperability
While HHS said it conducted outreach efforts to engage health IT stakeholders to better understand these barriers, we did too. To further understand what’s currently going on with healthcare interoperability, read the following perspectives from some of the industry’s leaders. If there’s something more that you think must be done to improve healthcare interoperability, let us know:
“Consumer pressure is driving a disruptive technology-enabled shift in healthcare today,” said Hal Wolf, HIMSS president and CEO, in a statement about the report. “Digital health technologies are beginning to deliver on their promise to help providers understand individual consumer preferences and provide personalized care that effectively coordinates care throughout the broader health ecosystem. By fully realizing the potential of information and technology, we can create an ever-increasingly informed and empowered global community of innovators, care providers, and patients.”
Specifically, the HIMSS report addresses four key trends: digital health implications and applications, consumer impact, financial and demographic challenges, and issues of data governance and policy. “Digital health tools have been riding the peak of the hype cycle for several years now,” the report points out, “but 2019 will be the year that digital health will need to answer for the way technology will increase access to care and narrow gaps in care and coverage.”
Given these areas of focus, it’s a good bet that the upcoming HIMSS19 conference and trade show will heavily promote these ideals. Even with that, there are likely going to be many other takeaways from healthcare technology’s biggest annual event so we asked some industry insiders, experts and thought leaders what they hope become the main takeaways from the event once it has wrapped. Here’s what they said.