Healthcare interoperability: The pathway to efficient member-centered care

The Centers for Medicare & Medicaid Services (CMS) has pushed to create a more patient-centered healthcare system with new interoperability standards since the past few years. The final rules laid out in March 2020 by CMS and the Office of the National Coordinator for Health Information Technology (ONC) are designed to facilitate increased interoperability and allow members greater control of their own healthcare data.

According to MarketsandMarkets, the global market of healthcare interoperability solutions is expected to jump from $2.3 billion in 2019 to $4.2 billion in 2024, rising at a compound annual growth (CAGR) of 12.6%.

The need for streamlined data exchange between different healthcare entities has been further magnified since the pandemic began. Payers will now be required to share their clinical, claims, and encounter data with other payers and members and publish their provider directory.

This would enable the healthcare system to provide more robust, competitive, and efficient member-centered care.

The benefits of healthcare interoperability:

• Enhance Star Ratings and risk management
  One of the primary priorities for payers is achieving high Medicare Star Ratings and scores on Healthcare Effectiveness Data and Information Set (HEDIS). One report on Medicare Star Ratings states that plan enrollment can be boosted by 8%-12% if a plan’s rating is boosted by one star, increasing revenue by as much as 17%. Improving member care and access to in-depth member data helps payers provide timely interventions and health plans while promoting better management of high-risk profiles.

• Empower providers to close care
  gaps Optimize care through cohesive payer-provider collaboration. Seamless access to data and EHRs can minimize gaps due to negligence or clinical errors and reduce fraud. This will ensure that members are always at the center during the care journey.

• Improve the member experience
  Giving members control of their healthcare data and access to medical records enables them to make informed decisions about their care. Access to 360-degree member profiles gives payers a complete view of their plan’s population and use the data to derive actionable insights to constantly improve member experience, which is a key factor for Star Ratings.

• Reduce costs across channels
  Interoperability helps reduce care costs for payers and provides comprehensive member and patient details that can reduce clinical errors such as repeated lab testing or prescribing inappropriate medications. Providers may work with multiple payer networks, and manage a significant number of patients which can lead to errors that increase costs. Efficient data management, interoperable and FHIR-enabled APIs, and configurable applications can help improve these outcomes.

• Support plans through population health management (PHM)
  The collective adoption of PHM, interoperability, and Social Determinants of Health (SDOH) enables insurers to create personalized care plans for high-risk populations by using advanced analytics and data management. This translates to member-centric and value-based care initiatives.

• Accelerate digital transformation and rise of telehealth
  Due to the pandemic, healthcare organizations have adopted telehealth and telemedicine options. Telehealth is here to stay, and it will only continue to rise through the rise of interoperability since it’s heavily dependent on a robust digital infrastructure and data exchange capabilities.

Interoperability is more than a compliance issue; it is key to the future of healthcare technology and payer-provider collaboration to deliver member-centric, high-quality care.

With the rules being slated to be implemented in 2021, it is evident that interoperability is more than a compliance issue; it is key to the future of healthcare technology with everyone involved to benefit. It is inevitable that there needs to be payer-provider collaboration to deliver member-centric and high-quality care.

To learn how to improve member-centered interoperability with the industry’s most comprehensive healthcare data platform for payers, get a demo.

For more updates, subscribe.