This is an exclusive interview conducted by the Editor Team of DistilINFO with Ankit Kumar Agarwal, Director – IT Delivery Services at NewWave Telecom & Technologies Inc.
Interoperability is a complex and challenging thing for the healthcare industry today. Different information systems, devices, and applications can access, exchange, integrate, and utilize the data beyond the boundaries to optimize global health needs.
Ankit Kumar Agarwal is Director of IT at NewWave Telecom & Technologies Inc. He currently manage the Healthcare Interoperability Product Development & Integration for the organization, which includes making the Healthcare Claims, and Clinical information available to 5% of US Medicare Advantage and Medicaid Population leading to improved health outcomes and resulting in billions of dollars in yearly savings for the Health Insurance Organizations and various federal and state agencies.
The healthcare system in the US is often criticized for being fragmented, inefficient, and expensive. Unlike many other developed countries, the US does not have a universal healthcare system, and many Americans are uninsured or underinsured. Healthcare costs in the US are among the highest in the world, and medical debt is a significant problem for many Americans.
According to data from the Centers for Medicare and Medicaid Services (CMS), national health expenditures in the US were $3.8 trillion in 2022, or $11,582 per person. This represents approximately 17.7% of the US gross domestic product (GDP). Healthcare spending in the US has been increasing steadily over the years and is expected to continue to rise in the future.
The US healthcare system faces several challenges, including:
- Access to Healthcare: Despite being one of the wealthiest nations, many Americans do not have adequate access to healthcare. Around 30 million Americans are uninsured, and many others are underinsured or have limited access to healthcare due to cost or geographic barriers.
- Rising Costs: Healthcare costs in the US are among the highest in the world, and they continue to rise. This puts a significant financial burden on individuals, families, and the government. The high cost of healthcare also makes it difficult for employers to provide comprehensive health insurance to their employees, which can result in more Americans being uninsured.
- Inequities and Disparities: Healthcare inequities and disparities are persistent problems in the US. There are significant differences in health outcomes between different racial and ethnic groups, income levels, and geographic regions. These disparities are influenced by factors such as access to care, social determinants of health, and implicit bias in the healthcare system.
- Lack of Health Data Interoperability: The healthcare data is fragmented, and the lack of standards for data sharing across various stakeholders makes it challenging to provide improved health outcomes for the members and reduce the significant investment in healthcare services.
The US federal government set up a standard to establish interoperability between the systems. The idea was to ease the flow of network communications across multiple systems, arrive at the right destination, and prevent obstacles in the early networking stage.
Healthcare today is at a similar stage, just like the early internet networking years. Data is the king in almost every business, organization, and entire process flow. When seen through the lens of the healthcare industry, data is a backbone for making better clinical decisions, processing claims, and managing critical record systems. When we talk about critical record systems, it doesn’t always make it easy to share the information between the providers, labs, and payers.
Interoperability is a complex and challenging thing for the healthcare industry today. Different information systems, devices, and applications can access, exchange, integrate, and utilize the data beyond the boundaries to optimize global health needs.
The Burden Reduction Rule places new requirements on Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children’s Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of healthcare data and streamline processes related to prior authorization, while continuing CMS’ drive towards interoperability in the healthcare market. This rule also adds a new measure for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category of MIPS. These policies, taken together, would play a key role in reducing overall payer and provider burden and improving patient access to health information.
The rule requires that, beginning January 1, 2026 (for Medicaid managed care plans and CHIP managed care entities, by the rating period beginning on or after January 1, 2026, and for QHP issuers on the FFEs, for plan years beginning on or after January 1, 2026), impacted payers would be required to make information available to patients via the Patient Access API about prior authorization requests and decisions (and related administrative and clinical documentations), including, as applicable, the status of the prior authorization, the date the prior authorization was approved or denied, the date or circumstance under which the authorization ended, the items and services approved, the quantity used to date, and, if the request was denied, a specific reason for the denial, no later than 1 business day after the payer receives a prior authorization request for items and services (excluding drugs) or there is another type of status change for the prior authorization. Beginning January 1, 2026 (for Medicaid managed care plans and CHIP managed care entities, by the rating period beginning on or after January 1, 2026, and for QHP issuers on the FFEs, for plan years beginning on or after January 1, 2026), impacted payers must make prior authorization information (and related administrative and clinical documentation) available to patients via the Patient Access API for the duration it is active and at least 1 year after the last status change. These proposals would apply to MA organizations, state Medicaid FFS and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the FFEs.
In order to meet the January 1, 2026 timeline, the payers would have to implement the key functionality by December 31, 2024, in order to meet certain CMS reporting requirements for the fiscal year 2025. CMS expects that the electronic prior authorization implementation duration for the majority of the plans could be between 18 months and 24 months.
Similarly, it is going to be a time-consuming effort to implement payer-to-payer and provider-to-payer data exchange. It is recommended that all of the plans start the planning exercise in Q1 2023 with a plan to start the design phase towards the middle of 2023 in order to meet the CMS-mandated timelines.
The act includes several provisions related to healthcare information technology and data sharing, including:
- The establishment of the interoperability and information blocking provisions, which aim to promote the interoperability of health information systems and prevent information blocking,
- The creation of a national patient identification system, which aims to improve patient matching and reduce medical errors
- The establishment of the Office of the National Coordinator for Health Information Technology (ONC) to promote the development of a nationwide interoperable health IT infrastructure
- Provisions that support the use of FHIR (Fast Healthcare Interoperability Resources) as a standard for exchanging healthcare information
- Provisions that support the use of APIs (application programming interfaces) to enable secure and seamless access to electronic health information
With the introduction of HL7 FHIR interoperability standards and the direct submission of prior authorization requests from EHR systems using a standard already widely supported by most EHRs, FHIR. To meet regulatory requirements, these FHIR interfaces will communicate with an intermediary who, when necessary, can convert the FHIR requests to the corresponding X12 instances prior to passing the requests to the payer. Responses are handled by a reverse mechanism (payer to intermediary as X12, then converted to FHIR and passed to the EHR). The direct submission of prior authorization requests from the EHR will reduce costs for both providers and payers (on average, $25 per prior authorization request), get rid of paper waste, and reduce greenhouse gas emissions. It will also result in faster prior authorization decisions, which will lead to improved patient care and experience.
When combined with the Da Vinci Coverage Requirements Discovery (CRD) and Documentation Templates and Rules (DTR) implementation guides, direct submission of prior authorization requests will further increase efficiency by ensuring that authorizations are always sent when (and only when) necessary and that such requests will almost always contain all relevant information needed to make the authorization decision on initial submission.