Category: Uncategorized

Value-based reimbursements have been much debated since both houses of Congress overwhelmingly passed the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) in 2015, setting the stage for Alternate Payment Models in Medicare, with incentives for providers embracing pay for value. CMS has been pushing value-based reimbursement models aggressively for years, recently introducing new reimbursements for Medicare and Medicaid members to address social factors such as isolation, food insecurity, and chronic conditions.

IT executives who responded to a recent HealthEdge-commissioned survey, conducted by Survata, cited value-based reimbursement as a top reason for modernizing their infrastructure. Of 245 IT decisionmakers surveyed, 96% said that the expansion of the value-based Medicare Advantage design factors into their recognition of the need to change.

The COVID-19 pandemic has also highlighted the flaws of the Fee-for-Service, with providers of all types experiencing delay of preventative and elective medicine resulting in revenue disruption. This has combined with the wave of hospitalizations of patients creating claims and requiring more manual processing, leading to higher costs for both health plans and providers.

Market pressures to adopt value-based reimbursement create an operational imperative for health plans, and core administrative systems must have the flexibility to configure all types of value-based contracts and benefit plans, from simple incentives to risk sharing, including full capitation. Configuration must also respond to changing regulations and competitive challenges quickly and easily, with minimum disruption and at low cost.

“The ability to stand up new plans and benefits and pivot to satisfy new CMS requirements has become very, very significant for us… a few years ago our claims and data platform was very old. We are on HealthEdge today. And it’s made a difference in how fast we can turn things around.” – Ghita Worcester, Senior Vice President of Public Affairs and Chief Marketing Officer of UCare.

UCare, a regional health plan in Wisconsin and Minnesota, has sustained a 96 percent retention rate over 20 years of proven experience with their Medicare Advantage line of business.

Another key to successful value-based arrangements is the partnership between health plans and providers, a traditionally challenging one. Health plans must not only construct value-based contracts with aligned goals for mutual success, but they must also provide actionable data on a real-time basis to their providers to avoid expensive encounters or hospitalizations. With this information, providers can quickly and confidently take key actions necessary for their patients to remain healthy.

HealthEdge customer Humana recently shared in its “2020 Value-based Care Report” that collectively, its 2.4 million Medicare Advantage members benefitting from value-based models spent 211,000 fewer days in the hospital and emergency rooms. Overall, the value-based agreements resulted in 10.3% fewer emergency room visits and 29.2% fewer hospital admissions, with a cumulative savings of $4 billion compared to original Medicare.

The premise of value-based models depends on operational readiness and data transparency. The results can be overwhelmingly positive for health plans, providers, and patients. HealthEdge customers report great success working with their provider networks to bring down costs while improving outcomes.

Regional non-profits and health plans wholly owned by hospital systems may be facing challenges in the market today, especially considering COVID-19. Analytics suggest patient volumes are trending downward, causing impacts to incoming revenue streams and creating constraints for these critical resources.

Therefore, it is not surprising to find some of these health plans are running on thin margins.

Rightfully, our provider-owned health plans are primarily concerned with taking care of their employees and members first and foremost; though, this tends to delay technology spending decisions.

As a customer-centric organization, we value patience and understanding and how important those values are in the payer industry. We live in an unprecedented time of difficulty that requires a critical level of care to ensure our customers’ success. In my experience in this business, any organization that lacks these ideals simply will not last.

As such, we must remain sensitive to the issues facing health plans, providers, and members that are out of their control. Working with the customers and prospective clients on their timelines, supporting their critical initiatives becomes our collective success story and our organizational paradigm.

You see, at HealthEdge, we make sure we always create customer value. In my experience, if we stay focused on creating value day-in and day-out, everything else will fall into place. The cycle of opportunities is constant. And when a previous opportunity with a prospective client does resurface, absolutely those customers remember the consideration and mutual purpose of success shown in a time of need.

I’ve built long-term relationships with people in this industry over the years, and being a reliable partner for our customers remains my top priority. It is so important to always put yourself in the customers’ shoes, understanding the obstacles they face on a daily basis. You must be sensitive to what they’re going through and remain supportive in order to provide critical value-based solutions.

The healthcare technology space is complex. Millions of factors can impact our business, but it is how we respond and react to those challenges that will build trust.

I care about our customers, and we need to do right by them. Their collective success is good for all.

Transparency in Coverage Final Rule

On October 29th, the Transparency in Coverage Final Rule was released and will be published in the Federal Register. We reviewed the Proposed Rule which impacts health plans, which would require health plans to provide personalized out-of-pocket cost information for all covered healthcare items and services.  This information that a health plan must post to its website includes in-network negotiated rates and out-of-network historical payment amounts using a very specific format at regular intervals. So basically, negotiated rates would be transparent to the world. Insurers that incentivize consumers by encouraging them to shop for services from lower cost and higher value providers will be allowed to use the shared savings in the MLR calculations.

The timeline of the Final Rule begins in 2022 and we will review the 500-plus page document in the next few days and begin to develop the HealthEdge Compliance Requirements and Position Statements.

• 2022 -Plans must post in-network negotiated provider rates, out-of-network coverage rates, and in-network drug pricing in a machine-readable format
• 2023- Plans must offer an online shopping tool or similar platform that includes an out-of-pocket cost estimate and negotiated prices for 500 of the “most shoppable” services
• 2024- The online shopping tool is extended to all services

The Final Rule also allows the plan to include in the numerator of the MLR any shared savings payments the issuer has made to an enrollee as a result of the enrollee choosing to obtain health care from a lower-cost, higher-value provider, beginning in the 2020 MLR reporting year.

In addition, because of the provider world’s current state, specifically hospitals, some clients are concerned about the Hospital Price Transparency final rule that becomes effective January 1, 2021. Hospitals will have to put the prices of their most common services on their website.

ONC and CMS interoperability rules

The Patient Access API and Provider Directory API will be enforced in mid-2021.

Right now, plans are likely focused on the current member portal technology that they have and how to leverage that for the patient access and provider directory APIs—the data will be similar, but the access points will be different. Many plans are also wondering about authentication and authorization management, meaning how a plan can ensure that they are only releasing information to the correct third party under the member’s consent.

A much heavier lift for health plans will be the payer-to-payer data exchange that will be enforced in 2022. At this point, it is unlikely that plans are looking to achieve the ingestion of payer-to-payer data. They are focused on the extraction and sending of the information. The ingestion is the more complex, requiring a look at how the information will benefit the member’s care by creating a continuum that can be used to guide the member’s care decisions.

HealthEdge is currently looking at the known data requirements in CMS recommended companion guides —CARIN Alliance Blue Button® Framework and Common Payer Consumer Data Set (CPCDS) and others.  We are assessing changes to the API and monitoring future requirements to ensure all data available from our technology is in the appropriate formats for their use.  We have plans to address the business use cases for the use of the received data in early 2021.

We are in the CMS world at the moment, and these requirements will impact Impacts Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-Facilitated Exchanges (FFEs).

Information Blocking

Going hand-in-hand with interoperability, the Information Blocking final rule goes into effect on November 2, 2020. This rule prohibits health providers, technology vendors, health information exchanges, and health information networks from practices that inhibit the exchange, use, or access to electronic health information (EHI). There are some exceptions that the federal government has put into place.

Although payers may not fit neatly into any of these categories, they do hold information that interoperability is trying to put into members’ hands. We will continue to monitor updates and the potential impact this rule could have on payers.

Additional news

In other news, discussions are ongoing between the National Committee on Vital and Health Statistics’ (NCVHS) and the Department of Health and Human Services on adopting a newer version of the X12N HIPAA EDI Transactions. At some point in the next few years, we can anticipate moving all of our EDI transactions to a newer version of the X12 rolls.

The final item is the CMS Annual Enrollment Period. On November 2 and November 3, CMS will conduct its CMS-generated rollover processing, a big deal for health plans. Some health plans may hit some bumps in the road and need our immediate attention and we are ready to support our customers.

For claims and pricing teams, managing fee schedules can be a massive headache.

With Medicare undergoing major quarterly updates as well as policy adjustments and retroactive changes coming in regularly, fee schedules require constant maintenance. Add in Medicaid policies and rates, perhaps across different states, and the lift begins to grow exponentially. And when there are new codes and policies coming about rapidly, such as we saw this spring with changes around the handling of COVID-19 testing and treatment, it can be nearly impossible to keep the information up to date.

Researching these updates and then manually loading fee schedules into a system requires time that many payers could devote elsewhere. Furthermore, ensuring that all information is accurate, and current, is a time-consuming process that is vulnerable to human error and leaves plans at risk of non-compliance or delivering over- and underpayments to providers.

In the ever-evolving health care landscape, health plans need a way to automate these processes. They need technology solutions backed by a policy team that handles the heavy lifting, takes care of the research, and manages and loads in fee schedules automatically, with rates and policies modified, tested, and operational on or before the effective dates. With cloud-based delivery, health plans do not need to lift a finger. This lowers costs, increases operational efficiency, and mitigates risk from a compliance standpoint.

This is an important issue not just for claims pricing teams, but for multiple areas of health plans. In HealthEdge’s recent independent Voice of The Market Survey, a study of 245 IT executives at leading health plans, the top challenge these individuals cited with their organization’s core administrative processing system, was low claims accuracy and auto-adjudication rates.

But not all health plans are the same, and every insurer has different contracts and unique billing requirements. Payers need the flexibility to configure their system to meet their specific business needs. They need a technology that can easily apply certain policies updates that match their business structure. With fee schedules loaded in and configured in a way that matches their business, health plans no longer need to worry about policy changes impacting their day-to-day business operations.

With less maintenance on the system and additional flexibility to make real-time updates, resources can be re-directed to more productive and innovative tasks. Empowered by the right technology, health plans will have improved accuracy, reduced waste, and adaptability in a changing marketplace.

I know regulations can seem overwhelming, but if you look beyond checking the boxes to ensure compliance, there is so much opportunity. I always try to remind the health plans I work with that regulations result from constituents going to their legislator with a problem that needs to be fixed, eventually resulting in a mandate. Beyond compliance, addressing these mandates can have positive results for the health plans and its members.

Think of interoperability, for example. It may seem overwhelming, but the concept of serving tailored, customized information to an individual is not far-fetched. If someone turns on their TV or opens a streaming service, the consumer sees a menu of options and suggested programming or channels of interest based on previous activity. With interoperability, individuals can apply that same concept to healthcare.

Traditionally, members have had to collect data from various sources—member portals, lab results, claims statements, and more— and try to figure out what it all means, and what to do next! Interoperability will pull that information together and make recommendations based on that information.

The driver behind interoperability is that patients, or members, want to know more about their own health. Interoperability provides information and analytics that could help individuals connect the dots and take away guessing when it comes to their healthcare. Interoperability empowers individuals to address their concerns, ask questions, identify additional steps, and lifestyle changes they can take to improve their well-being and have the full picture of their health.

For members, interoperability is about getting access to the right information. For health plans, interoperability is about collecting and sharing that information.

To make interoperability successful in healthcare, health plans need the right technology and, almost more importantly, sound business processes, resulting in good data. Anyone can learn how to do FHIR-enabled APIs. But understanding how a claim should come in, how it should process in the system, and how it produces the information needed to be consumed by the APIs is very important. Payers should focus on the claims administration system and ensure they’re collecting the right data consistently so that they can provide the right message to the patient, other payers, and providers.

The alignment of business and technology, especially in this industry, is becoming increasingly important. To be successful, technology leaders, including CIOs in healthcare, must understand and become a part of the business they support. Effective partnerships outside of IT will strengthen the CIO’s influence.

The IT department is at the center of business decisions and initiatives. Once a need is identified, the IT department will work with the business to deliver a solution. Before delivery begins, technology leaders often must handle the contracting process and act as the liaison between solution provider, procurement, and legal departments.

Because technology leaders work with so many systems and vendors, CIOs can spend significant time on contract negotiations and tracking contract renewals and expirations. This can be time-consuming and reinforces the importance of fostering strong partnerships with departments and leaders throughout the organization. These relationships, or lack thereof, can make or break the implementation of technology to address a business issue.

When it comes to purchasing decisions, technology leaders are also often faced with obtaining support for technology investments from other executives or the Board of Directors. Strong relationships are essential for success in this area as well. There’s ROI that comes into play, too, beyond just keeping costs low. When making new technology investments, there is often an increase in cost before savings are eventually recognized. When a CIO needs to convince stakeholders, who may not be intimately involved with the projects, it’s important to always tie the purchase back to how it drives business value.

With technology implementations, there will be bumps in the road. Technology leaders must acknowledge this reality and share this with their business partners. The goal is to react and resolve quickly. It is essential to be transparent and set realistic expectations from the beginning. Being transparent minimizes surprise and gives the CIO credibility. Sincerity is key to forming successful partnerships with stakeholders. Once stakeholder trust and support are established, work becomes more enjoyable, and relationships thrive.

If a CIO in healthcare is solely focused on technology and does not appreciate the business perspective, it will make the job difficult and more stressful than necessary. Business and technology leaders must work together, share their insights, and form strong partnerships to achieve their organization’s goals.