CMS & ONC Propose Big Changes for Payers

While much has been made about how the proposed rules on information blocking and interoperability from ONC and CMS will impact providers, patients and health IT companies, there has been surprisingly little discussion of the new requirements for health insurance companies. But make no mistake: these rules have major implications for participating insurance providers and they are scheduled to take effect beginning in January 2020.

In this special edition of 4x4 Health, we turn the spotlight on this important issue with Nikki Kent, Senior Vice President of Operations at Sansoro Health.  Nikki has decades of experience working with both payer and provider organizations, including 15 years at Optum and UnitedHealthcare where she served at VPs of Client Services and Compensation. Nikki’s experience with organizations on all sides of the health IT, make her the perfect person to provide an overview of the challenging technical, business, and compliance requirements that payers are set to face in the very near future. 

To learn more about the proposed rules and ongoing API revolution in healthcare, be sure to check out the rest of our series on ONC and CMS as well as our API 101 episodes.

Dave: Welcome to 4 x 4 health, sponsored by a Sansoro health. Sansoro health; integration at the speed of innovation. Check them out at www.Sansorohealth.com. I’m your host Dr. Dave Levin. The recently released proposed rules from ONC and CMS on interoperability and information blocking are getting enormous attention as they should. These are some of the most import issues on health IT today. And with all the focus of the impact of these rules on providers in health IT companies, it’s easy to overlook the impact on insurance companies. But make no mistake there are substantial new technical and business requirements that are coming and coming very soon. In this special edition of 4 x 4 health, we’ll take a high-level look at these new requirements and their impact on payors, providers and patients. Today I’m talking with Nikki Kent, senior vice president of operations at Sansoro health. Nikki is an accomplished health care executive having specialized in operations, human capital and sales for payor and provider organizations. Before joining Sansoro, Nikki spent 15 years at Optum and united healthcare serving as V.P of client services and V.P of compensation focused on sales in [unclear]. Having worked closely with Nikki for several years I can attest that her executive experiences in the health insurance, operations and health i.t. put her in a great position to offer valuable insights and practical advice about these coming regulations. Welcome to 4 x 4 health Nikki.

Nikki: Thanks Dave, glad to be here.

Dave: Before we dive into the rule’s discussion, Nikki take a minute and just tell us a little bit about yourself and your background.

Nikki: Sure. So I have a bachelor’s degree in history, which naturally lends itself to health care. So when I started out in college I thought I wanted to go to law school and master in political science majors and had an opportunity to actually have an internship at a health system and of all things for managed care departments and this was back in the mid-90s when capitation was starting to become big and payers and providers were trying to understand how to work together and manage risk. And I quickly realized that this was way more exciting than going to law school and shifted gears and came to Minnesota to the Carlson school of management to get my master’s in health care administration degree. And since that time I had an opportunity to work in large health systems, like cost of health as well as large payor organizations like united healthcare and Optum. And I’ve been able to then take the information and the experience from my educational payroll provider background and have spent the past two years at Sansoro health looking for ways in which we can use technology to enable health systems, help payers and other providers of healthcare information technology to further and better our healthcare system.

Dave: Well I chuckled at the history background. But one of the themes of this podcast has been how important it is to have diversity of experience and points of view at people that have been in healthcare a long time like you have and folks that have come from outside health care and quite honestly I find people who’ve had degree experiences outside of the sort of usual suspects of medical degrees and an administrative decrease bring some of the most helpful and interesting perspectives. So good on you and we need more folks like you helping us fix healthcare. You know you and I both share some background. I did spend some time as a senior medical director at a health plan in Virginia and got a pretty good education in sort of the philosophy of how payors operate as well as some of the details of operations. And of course you and I recently looked at some of these proposed rules and there’s a blog post which we recently released, and we’ll include that on the website. What I really want to do today is not so much get into the dirty details here, but really focus on you know sort of at a high level what’s in the rules and what the impact may be. So let’s turn to the rules now and I want to begin with really looking at, well broadly what’s being proposed and who’s being impacted. And as I looked at this there’s a couple of really key things here. First is to note that a lot of these mandates are coming from CMS. ONC is more of a backseat in this particular arena at least when it comes to payers. And there’s some fairly significant new mandates, particularly around exchanging data between payers and between payers and providers. And there were a couple of things that I think jumped out at you and I when we began to look at this in preparation for writing our article. First was that this is really patient driven. It’s the patient requests are going to drive this kind of data exchange that there’s very specific mandates about the clinical data set in having an API that’s available to move that data. So really parallels the ONC requirements around using FHIR to deliver the U.S CDI dataset. There’s some administrative features to this and strikingly that these payers are going to be expected to keep an exchange up to five years of data again on demand by patients. So that was a lot.

Nikki: There is a lot in the rules.

Dave: There is a lot in the rules. So real me back in here a little bit. I mean is this what you saw and what is your take on some of these big pieces as well?

Nikki: It is. You know when I take a back and say okay why is ONC and CMS proposing the world around interoperability. The focus is on patients and how can they obtain and use their electronic health care information and be able to do so in a way that is intuitive to the average healthcare consumer. So looking that I can obtain data on a tablet, data on a pc, and while today some of that information is available as a consumer, I would have to aggregate that manual from all of these different sources. And there’s no consolidated way to obtain that information. The standards around how I can do that. And so if I’m looking to do that to manage my own care, it’s very challenging. And so when I look at what CMS and ONC has had proposed, it’s really around what do we as consumers need to have in order to be able to take control of our own health care data and information. And that really comes down to how do we get information from providers and how do we get a permission from payers. Because they’re the two primary holders of our healthcare data and information. And so when I look at what’s been proposed, it’s really around how do we structure that in a way that allows consumers to get the information they need and get the longitudinal information as you eventually gave around the past five years and my payer needing to be able to transfer my information to a new payer for up to an additional five years. So that future payers that may be insuring me, future providers that may be providing care to me can have this full and complete picture and can help make the best health care decisions for me and I can take advantage of that to do the same both clinically and financially.

Dave: I think that’s a really great perspective on this, because it puts the patient right in the middle. And you know one of the things that strikes me about all this is that the payers, the insurance companies you know they sit in a kind of unique position. Because they interact with both patients who they insure, and they also interact with the providers who render care and want to get paid for it. So they’re in a kind of unique position and in theory could play an important matchmaking role. The reality is has often fallen short of that. And as I like to say you know payers and providers have been fighting over reimbursement since the dawn of time. And so it doesn’t really set up the healthiest kind of relationships for this sort of collaboration. So what’s interesting to me about this is, if you agree with that point of view and I definitely want to hear what do you think about that, is that these rules address not just the technical aspects but also they really get at some of these relationships and business relationships as well. Which I think are also a barrier. You’ve been in this is longer than I have this. What do you think about those observations?

Nikki: I absolutely agree. And you and I have had the experience of sitting on both the payer and provider side of the fence and there is a lot of mistrust. There are our fragmented systems for how they interact with each other. There are the underlying business agreements as you talked about with reimbursement that can oftentimes make relationships challenging. And then you’ve got the diverse services that are being provided. So one of the interesting things or challenges where opportunity is, I guess with the proposed rules is that this is targeted at a qualified health plan and those health plans that are offering insurance services to individuals that are receiving care through a federal program. So I guess federal or state through state Medicaid, through chip, through Medicare advantage type plans. And what’s interesting is this is the focus of the mandates. However as we know most insurance providers out there, this is only a portion of the business that they do, and they’ve got an equally if not larger commercial population as well. And so where we may look at some unique relationships that exist today and challenges between these health plans, it goes much further than that. And it starts to bleed over and causes us to question while these rules are being proposed just for the federal programs and then state programs. What also will be the implications for how and if major health plans decide that they’re also going to extend this to their commercial population. So that we as consumers can get the broadest benefit. But again you know when we look at the back end systems and how these health plans are organized, the complexity that exists just with the Medicare and Medicaid type programs is very challenging in and of itself let alone trying to think about how going forward to really get the most bang for the buck. We extend this to the commercial plans as well.

Dave: Well I want to come back to this issue of the fragmented backend systems in a minute. But before we do that, I want to repeat something you said that I want to push you further out on the limb that you just inched out on to here. So you made a really important point here. Which is you know this applies and there’s some nuances in how it applies to the various federal and state programs like Medicaid. Doesn’t apply broadly to the broader commercial market, but it’s a really interesting question about how and if they will follow [unclear]. And as I said you sort of started to inch out on that limb. So let me push you all the way out there and get you to speculate a little bit. What do you think these commercial payers will do? What’s your sense of how they may respond to this changing situation?

Nikki: Yeah you know I think from the start, the intent spoken or unspoken of CMS was that these rules would extend more broadly into you, into the commercial health plan space as well. I think that it is important and would be a smart business decision for commercial health plans to take a hard look at extending these interoperability standards more broadly across their entire population. While not mandated. It is the way that we are going in the industry and if interoperability is good for one segment of the population, quite honestly, it’s good for the entire population. I think the challenges that have been raised by industry groups and individual payers is the concern over the cost and the timeline around what it’s going to take to implement this. And I don’t want to get into the fragmented back end systems again. But oftentimes my experience with payers has been that there isn’t a single back end system that supports all of their lines of business. And so while we can all agree that it makes sense to want to extend this. I think that unless mandated to do so, it will take time, it will take quite a bit of time to get the health systems there to be compliant and extend this to their commercial populations as well.

Dave: Yeah, I tend to see this the same way. I mean historically you and I both know from having worked inside these organizations, they tend to mirror what CMS does. They may be selective in what they choose to mirror at the pace. But it’s you know the classic example is rate adjustments and so

We’ve seen this and I think it’s really so fascinating about all this is I really see this as addressing a market failure. Because if you really really step back and you set aside some of the difficulties of the relationships, there is enormous benefit to all three stakeholders here. This is clearly better for patients. It’s also better for providers they’re going to have a more complete picture, more ready access to data and for payers, having access to this rich kind of clinical data has been a really important objective for quite a while. So I agree with you. There’s some counterbalancing in there in terms of how far and how fast and some of the technical complexities. I think there’s a pretty compelling business case for them to move in this direction. Am I being too much of a sunny optimist and I need you to call B.S on me here or just that square with your, with some of what you see as well.

Nikki: No, I think it absolutely does square with that. You know I think one of the things that will be key to determining how quickly the payers are willing and able to go, especially extending into the commercial space is how the costs associated with compliance with these rules impacts their medical loss ratio and whether or not they are able to accrue the cost of compliance to that as a quality measure. As we know when you start getting into areas of reimbursement and MLR requirements, those are very closely managed by payers and to the extent that they’re able to rap that and I think it will have a significant impact on how fast they go.

Dave: So I think that’s a really critical point. I just want to elaborate on that a little bit. It’s for those who are not immersed in the insurance industry, little bit inside baseball here. There are typically federal and state requirements about the percentage of fees or income that’s devoted to operating a health plan. And the good news is that for these proposed programs where they impact, these expenses get credited towards that. So that’s a benefit to the insurer. Rather that will extend more broadly to commercial programs is an open question. And then as you point out there’s other costs and other benefits to be weighed into this. But it’s an important nuance particularly to those in the industry. The last thing I want you’ve mentioned several times. I think it’s really important to emphasize, not only are these rules come in, they’re coming fast and so some of the initial requirements go into effect on January 1st of 2020. So less than six months from now and the remainder come into effect by July 1st. So within the next year. Now you and I have speculated that, these deadlines may be extended a little bit given where we are. But it’s real clear federal governments not messing around here, either with the scope of these requirements or the pace at which they expect to go. Does that sound right to you?

Nikki: It absolutely is. And I think that when I look at payor organizations in particular, I think they’ve got varying abilities with their in-house technology and their current data strategies to be able to meet those deadlines; the 1 1 20. And as you mentioned and as a number of industry groups have responded in their comments to the ONC is that this is going to be a big challenge for them. Yet it is not an insignificant list. And while there have, while the proposed rules have laid out some standards around the data elements that need to be exchanged in the way in which API used to be presented as open and accessible APIs, there isn’t a recipe book for the payers to follow or to copy and paste to get these APIs made available. And so I think that there will be a heavy lift on the payers in order to both make the data available as well as the flip side, which is again, they have to be able to ingest this data from other payers. So the less formal standards and in regulations around what data is exchanged and how it’s exchanged can, while it may be a benefit to a payer to be able to then mold and model how they want to present the data for their own health plan, it presents challenges industry wide. Because each of these payers need to be able to take in and consume this data from other payers and providers. Which again without some clear standards around that could also be very challenging.

Dave: Well Nikki, boy I heard so much of you reflected in that little discussion there. You’ve gone right to the, okay so what are some problems and how are we going to solve those. And I want to get deeper into that. But first I just want to remind our listeners, if you’ve just joined us, you’re listening to 4 by 4 health. We’re talking with the senior vice president of operations at Sansoro health, Nikki Kent about the proposed rules from CMS and ONC for payers and given Nikki’s background in the insurance industry, she’s helping us understand both the broad view and some of the real specific challenges that are coming at this industry very quickly. So Nikki let’s continue down this road of challenges and you know I sort of think of those as divided into the technical sphere and the business agreement sphere. You started to give us a pretty good overview of the technical, so let’s stay there for a minute. As you noted these are very significant requirements in terms of the scope of data, the types of data. It’s not just administrative, it’s clinical. It’s fairly specific about the types of clinical data. It’s fairly specific at least where data exchange standards are available to be used. Bottom line is there’s going to be a lot of work to do around this. The good news is we’ve got some emerging standards and some technology very well proven in other industries that’s starting to catch on in healthcare. I’m specifically talking about of course application programming interfaces or APIs and the emergence of the FHIR standard API as a way to exchange core clinical data set. So when I look at that I go all right, well this you know again this is something we need to do as an industry. We’ve got some tools to help us get started. And it certainly parallels what we’re seeing on the digital health side. But you’ve raised a really important issue, which is that the backend systems in payers tend to be very heterogeneous and can be fragmented. My impression is they can also be really highly customized. So I know you’re not an i.t. expert, but you’ve had to deal with these things. Take us on a little tour of what you’ve seen and your understanding of some of these backend systems and how that’s going to fit with some of these core solutions.

Nikki: Well I think you’re absolutely right that there is fragmentation in the industry. And so just like the provider industry, the payer industry has gone through quite a bit of consolidation and continues to do so. And so when you look at some of these, especially the large national payers what you’re going to find is that there are multiple backend systems that support the different products that they offer and some of those may be specific to insurance requirements for individual states in which they operate as well as more broad nationwide industry standards. Then layer on top of that the different, the different offerings that they have. Whether it’s a commercial plan, whether it’s a Medicaid plan, whether it’s a Medicare advantage plan and you start to have different reporting requirements that have been historically in place around each of those. Each necessitating different types of data and in some cases different underlying data models and specialized systems to support that. And so as the industry has changed and evolved, the payer industry has needed to change and evolve to keep up with that. And as we know how each state decides to administer health insurance varies greatly. And so that has in part along with the consolidation overall in the industry led to quite a bit of the fragmentation that exists in the backend system structure.

Dave: God you’re giving me like a flashback, that slight nausea as I recall my day’s working in the health plan and the amount of effort that went in to customizing and maintaining these back-office systems. And I think you described it perfectly. I mean it’s this mishmash of federal requirements, state requirements, things specific to that particular insurance company. And this is all layered on top of a variety of software systems and they’ve tended to be adapted and customized over time. So it’s a real tower of babble out there. Wouldn’t you agree?

Absolutely, absolutely.

Dave: The good news that I see in this and of course you and I are biased, because it’s work, we’re deeply involved in these days is I think this combination of API technology, the emergence of the FHIR standard and it’s become more mature over time. And I would also add the emergence of increasing use of the cloud as a way to store and secure data presents a really interesting opportunity to address this in ways that we couldn’t in the past and frankly give me a whole lot of hope. So let me be really direct. I look at this and I go, thank god APIs, FHIR and the cloud are going to come to the rescue here. That combination can fairly quickly be put together with the right knowledgeable partners to offer a solution that essentially functions as a Rosetta Stone between all of those back and diverse systems and a kind of mapping to this new standard as well as a way to deploy it quickly, secure it to health care standards and scale it as necessary. Now listeners to this podcast and my friends know I tend to be a sunny optimist and I’m sure there are more devil’s in the details there. But do you see what I see, or do you see something different and again I’ll remind your guests on 4X4 health are not only allowed they are encouraged to call B.S on Dave. So have at its Nikki.

Nikki: Unfortunately I can’t in this instance. Because I do agree with you. And you know I look to other industries to have gone to the cloud who have utilized API that have developed industry standards and in the financial services industry is a perfect example of that. And we don’t think twice anymore about our ability to get our consolidated financial information through [unclear] or to go to any A.T.M. in the country and know that we can track the balance on our accounts and know that that’s going to be accurate. And I have great hope that over time the healthcare industry can follow that model through the use of API, through the use of industry standards like FHIR and through cloud which provides us with that secure any time ability to access data. So I think you’re absolutely right. We need to recognize that this is the first step and that it will continue to evolve. FHIR standards will continue to evolve. The adoption of cloud hosting of applications and health care data and HIPPA compliant high correct certified environments are going to continue to expand. And so we can’t expect that this first version is going to be the complete Rosetta Stone. But I do I do believe that it is providing the foundation on which it will be built.

Dave: Yeah, I couldn’t agree more. I think you did a nice job of balancing the hope with a little bit of realism. Not always my strong suit. So I appreciate that. But I think it’s right. I mean you know my initial reaction when I read this was you know it’s sort of projected back 10 years ago and went oh my god I would have been completely freaking out in my health plan role thinking about, how in the world are we going to meet these requirements using legacy technology. This combination though of API technology, secure cloud systems. And as we’ve talked about the emergence of FHIR and frankly the ability to build custom APIs really give us the right tools to go solve this in a much more pleasing sort of way. So we are right to be cautious. And you’re right to point out that we’re not going to build the whole Rosetta Stone all at Once. But I think we have the makings of the tools to do it in a particularly powerful and relatively efficient way. So I’m personally excited about that and looking forward to seeing that.

Nikki: You know I am too. I think the industry is ripe for this type of innovation and I think that it does give me hope, it does give me you know the belief that we will find a way to utilize technology to truly enhance the engagement of patient and in their health care through data from providers and payers.

Dave: Yeah, I couldn’t agree more, and I think the other good news is that although API technology and the use of secure cloud is relatively new to healthcare, widely used in other industries. Lot of progress in health care particularly in the last two years and so I have a high degree of confidence in the ability of those kinds of approaches to work well to solve these types of problems. I want to turn to away from the technical challenges to the, if you will what I call the business agreement challenges and I want to look particularly at one which I think could be really fun to watch and essentially comes down to this, the federal government through CMS can mandate to the payer, hey gather this data, keep it for this period of time. Make it available in near real time frankly to patients. But getting that data from the provider, so the providers supplying the data and having them serve it up in a timely fashion so the payer so they can meet that is more of an open question. And at least in the CMS portion of the rules they call this out as an issue and although there’s nothing in it that I can see that specifically addresses this. I think there’s two things I did pick up on it and I’m curious about your take on them. So the first was that this is rolled into the information blocking reporting, so that if a provider or payer or if a provider, if a payer sees a provider not cooperating that is supposed to be reported under the new disclosure requirements for information blocking. Now you and I both know there’s the, there’s the option to report and then there’s the business decision about whether that’s a wise thing to do or not. But the other thing is CMS is very forthright and says literally in the proposed rules, payers may want to revise their agreements with providers in light of these data exchange requirements. And as you pointed out earlier that might just include the qualified plans or perhaps it just becomes an expectation across all of their plans. So let me summarize all that. I’m sorry I went on a little bit of a spree there. But to me the business agreement issues are as interesting and as challenging as the tech. But the one of particular interest is the ability of providers to serve up the data to the payer in a timely fashion. And you know how that will actually get addressed through enforcement and collaboration and potentially through contractual changes.

Nikki: Right. And I think that is one of the big unknowns as we go into this. There’s a portion of the data that needs to be made available that’s specifically tied to medical claims. And so you know when we look at that component of it, it’s probably the most straightforward in that it’s taking information that the providers needing to submit to the payer for payment of a claim anyway and then requiring the payer to tee that up relatively as you said near real time experience and that within one business day the claim being processed, that data needs to be available via an API. There are other aspects of the rules that are going to be much more challenging for the providers to tee up. And so when we start looking at some of the requirements around admit and discharge data and transfer information and lab results and in some of that information that isn’t necessarily all being required on the same timeline to the same parties, that’s going to be I believe much more challenging for providers to be able to structure their systems in order to generate that type of data as well as for payers and others to determine how they want to ingest that data and how they’re going to store it in order to be able to report on it in the future. And so I think that those are the aspects that while vitally important, when we look at the continuum of healthcare more challenging as it hasn’t, it hasn’t been done in this fashion before and will require a lot of thoughtfulness and planning and action to accomplish.

Dave: I think that’s a terrific summary and let’s just pick up on that and we’ll wrap up today just with a sort of broader summary of all of this and maybe we can extract a little sage advice from you as well. So to your point when this is implemented at least from my point of view, it’s going to have a profound impact on the data exchange and the completeness of what’s sometimes referred to as the longitudinal record and that has a great potential benefit for everyone. Obviously for patients, for providers to have a broader review as they work with patients and advise them and also for payers as well as they devise better offerings, more efficient ways to do what they do and the like. So my first sort of summary would be, this is both important and I think kind of exciting too. Would you agree with that?

Nikki: I absolutely would. I think you know when we, when we look back over, I guess the more recent future and we see what’s happened with the introduction of EHR into the healthcare industry, this is the next evolution. This is the next big thing. We started to gather health information electronically in disparate systems and now we’re really getting to the point where we can really turn that into actionable information that can be used more broadly within the industry to as you said, you know get more of that longitudinal view of an individual’s health. And I personally find that very exciting and think it’s the next right evolution for health care.

Dave: I couldn’t agree more and I’m especially hopeful that that’ll be the case. If the commercial payers follow suit and as we discussed there’s reason to believe that will happen. Neither one of us wants to predict the pace or scope of that. But I believe it will happen. I think the other really important message here is these are big changes and they’re coming fast. There’s a significant technical lift, there’s some things to look at in terms of business agreements. This presents both a challenge, but also an opportunity for you and I talked about you know some not necessarily technology or approaches that health plans have a lot of experience with. But fortunately there are a lot of experienced folks out there who do know how to leverage API technology, do the sorts of mapping that we’ve talked about to these standards and also as you and I suggested this is something that’s particularly right I think for cloud based solutions. So I see this as another one of these sorts of paradoxes of this is really good stuff, but it’s some big changes they are coming fast. The good news there is there’s some substantial experience out there that can help companies get up to speed on this and probably get some additional benefit out of it. So again I’ll give you the opportunity to either elaborate or correct what I’ve said.

Nikki: No I think that’s absolutely absolutely correct. And there are a number of individuals and organizations within the healthcare industry that have started to adopt the usage of APIs and the advent of the cloud for hosting this data. You know one of the challenges that’s been based in the industry and I think we’re going to have to as an industry get comfortable with is this notion of utilizing the cloud to host this data. Hospitals have and health care providers have typically felt more comfortable retaining healthcare information within their four walls. And that was how they were brought up. Whether it was from all paper medical records to you know moving things to servers again kind of within the four walls of the hospital or quite honestly even payers themselves the same way within their own data centers. And to now be able to manage the amount of information, the need for the near real time flow of information and accessibility of information, I would argue that the cloud is the only way to go into really meet these needs in the future. And there are a number of things that are being put in place or have been put in place by multiple cloud providers to ensure that the data is secure and remains confidential in that environment and that’s still accessible via APIs to the payers, providers and patients who will need it now and in the future. So I think you’re, I think you’re absolutely right. Use of API, use to the cloud is really going to be critical in order to bring this to life.

Dave: Yeah, I think that’s right, and this may well be the tipping point that for our industry to go there. There’s a kind of irony in all of this because in some ways it is a more secure environment and easier to demonstrate compliance. But we will save all that for another podcast, because those are pretty deep topics here. I do want to remind our listeners we’ve got additional information on these topics. You and I recently published a blog post on this as well. We’ll include the links to all of that on the web site for this podcast as well. Just to give folks some to do some follow up where that’s helpful. Nikki I really want to thank you today. Not at all a surprise given your background and diverse experience. I think you’ve also helped us understand some of these issues more clearly and definitely offered some sage advice. Thanks so much for that.

Nikki: Thanks for having me Dave.

Dave: We’ve been talking with Nikki Kent, senior vice president of operations for Sansoro health. Nikki thanks again for joining us today.

Nikki: Thank you.

Dave: You’ve been listening to 4 x 4 health sponsored by Sansoro health. Sansoro health, integration at the speed of innovation. Check them out at www.Sansorohealth.com. I hope you’ll join us next time for another 4 x 4 discussion with health care innovators. Until then I’m your host dr. Dave Levin. Thanks for listening.