CMS continues to set its sights on interoperability and data sharing

The Centers for Medicare and Medicaid Services (CMS) recently proposed the Advancing Interoperability and Improving Prior Authorization Processes rule that would work to ensure healthcare data is securely shared among providers, health plans and other stakeholders. The rule would set for the establishment of application programming interfaces (APIs) that allow for better communication between applications. The establishment of APIs would advance data-sharing and interoperability and improve prior authorization processes in the healthcare industry. It also aims to reduce the burden of prior authorization processes by providing more streamlined access to medical records and other related information. Additionally, the rule includes provisions enabling patients to access their medical data more easily and ensuring that providers can access accurate patient information when needed.

Building on data-sharing

The proposal builds on the policies finalized in the CMS Interoperability and Patient Access final rule and is now open for public comment until March 2023. The rule would mandate state Medicaid agencies, Medicare Advantage organizations, managed care plans and qualified health plans participating in federally facilitated exchanges to develop and manage APIs that support the transfer of clinical and claims data.

Organizations that participate in federal health programs would be required to:

• Create a Fast Healthcare Interoperability Resources(FHIR)-based API to allow insurance companies to exchange clinical and claims data (without cost information) for members who switch plans
• Expand the information available to consumers to include the outcome of prior authorization decisions
• Develop a FHIR-enabled API for payers to share clinical, claims, encounter data (without cost information), and prior authorization requests and decisions with in-network providers to support value-based care and payments
• Create a FHIR-based API that automates the process for providers' determination about whether prior authorization is required, what data is needed, and how to exchange requests and responses electronically

The rule also seeks to reduce prior authorization response times. Impacted payers must send prior authorization decisions within 72 hours for expedited requests and seven calendar days for non-urgent requests. Payers will need to report prior authorization metrics publicly by posting them directly on their websites or a publicly visible and accessible link annually. Providers would also need to report the number of prior authorizations for services requested through the APIs that this new ruling seeks to establish.

Overcoming technical and cultural impediments to using shared data

Although interoperability has become a household name for health organizations, the complexity of doing more than just exchanging patient data to achieve true level 4 interoperability continues to grow. Many health organizations still have a long journey ahead to reach this goal. As healthcare becomes increasingly digitalized, interoperability among disparate systems can help reduce prior authorization times, improve patient outcomes, and streamline care delivery.

Level 4 interoperability enables faster communication of patient information, leading to better decision-making. Additionally, it reduces the administrative burden on providers by allowing them to access all relevant patient records quickly and easily. Data sharing beyond traditional means establishes long-sought-after transparency in the healthcare system by providing a unified view of all relevant data points related to a patient’s care journey, thereby creating a truly connected health ecosystem.

Solving the data-sharing dilemma

The Advancing Interoperability and Improving Prior Authorization Processes ruling shows that CMS understands the need to create standards for sharing health information across stakeholders. Equitable and unbiased access to data is also necessary. Data-sharing networks owned by a single health organization whose motives are to leverage shared data to achieve competitive superiority will always be an impediment to achieving true interoperability.

For health systems and plans to be truly interoperable, they must overcome technical and cultural impediments to using shared data for true patient centricity and access. Doing so isn’t easy, but it’s certainly not impossible. In fact,our latest viewpoint paper provides key insights for solving some of healthcare's long-standing data-sharing dilemmas.