How can ACOs Manage Medicaid Contracts Using FHIR-enabled data Activation platform?

Paul Grundy
Wed 03 Jun 2020
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The U.S. Department of Health & Human Services (HHS) recently finalized two historic rules to give patients more control of their health data. Under HIPAA, providers shared health data through Electronic Health Records (EHRs) with other providers. But under the new rules, providers must share that information with patients, providers, and other parties unless they meet one of eight exclusions outlined by HHS. These rules will give patients more control and access to their health data and empower more consumers to share data with the companies they trust. 

The Fast Healthcare Interoperability Resource, commonly known as FHIR, has quickly become one of the most popular protocols for joining disparate systems and holds great promise for the development of an application-based approach to interoperability and health information exchange. 

The current state of EHR data access and bolstering interoperability

The opportunities to leverage electronic health records data today are far superior to those that existed just ten years ago.  But even with the abundance of EHR data available, it’s the access to that data that is lagging and stifling innovation within our larger healthcare ecosystem.

The focus of various health data integration approaches is to provide for more robust treatment & care within a healthcare setting. According to a CDC report, As of 2017, nearly 9 in 10 (86%) of office-based physicians had adopted any EHR, and nearly 4 in 5 (80%) had adopted a certified EHR. Since 2008, office-based physician adoption of any EHRs has more than doubled, from 42% to 86%. 

However, many of those certified health IT products lack capabilities that allow for greater innovation in how health information can be securely accessed and easily shared with appropriate members of the care team and patients. 

The 21st Century Cures Act provided the U.S. Department of Health and Human Services (HHS) with greater authority to enhance innovation and scientific discovery to expand access and use of health information. As HHS continues to implement the Cures Act, the government and industry continue to work together, giving rise to an enhanced focus on open APIs. APIs are a technology that allows one software program to access the services provided by another software program and can help EHRs and healthcare data to be put to better use. Therefore, the use of APIs can improve access to and the exchange of health information.

Interoperability for Medicaid providers and ACOs  

Currently, CMS shares Medicare claims data through Claim and Claim Line Feed (CCLF) files. These CCLF files provided monthly to Shared Savings Program (SSP) ACOs include Medicare claims data. For instance, data of beneficiaries receiving care outside of the ACO, allowing a full picture of patient care. Representatives of Shared Savings Program ACOs are now slowly shifting to standards-based API called Beneficiary Claims Data (BCDA). The goal of the BCDA is to provide Accountable Care Organizations with the same claims data they were receiving in Claims and Claim-line Feeds (CCLFs). However, this data will now be delivered in a new format. CMS intends for BCDA to meet four main goals for SSP ACOs:

  • Improve ease of access to bulk beneficiary claims data
  • Decrease the time for CMS to implement any required or requested updates to support the ACO program
  • Reduce the burden on ACOs for changes to the data or data format
  • Enhance efficiency by enabling system-to-system communication and reducing the need for manual intervention to retrieve and manipulate the data

CMS requires states to send enrollee data daily beginning April 1, 2022, for beneficiaries. Apart from this, Medicare and Medicaid participating hospitals will soon be required to submit electronic notifications to another healthcare facility or community provider or practitioner when a patient is admitted, discharged, or transferred.

Improving management at ACOs and other benefits of a FHIR-enabled data activation platform

FHIR (Fast Healthcare Interoperability Resources) is a specification for exchanging healthcare data electronically, allowing any system to access and consume this data to solve clinical and administrative problems around healthcare-related data. BCDA is built on the Beneficiary FHIR Data Server (BFD) API, which has structured its data using the FHIR standard. BCDA uses three resource types from the FHIR specification: an explanation of benefits, patient, and coverage. ACOs can use this FHIR-based API to retrieve bulk Medicare claims data related to their beneficiaries. The data helps evaluate the performance of ACOs and assists in conducting quality assessments, driving care improvement, and conducting population-based activities essential to improve health.

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Innovaccer’s FHIR-enabled Data Activation Platform can help leverage smart automation for care management and enhance population health outcomes with data and analytics

“ACOs can’t continue to use claims data as the only real source for their analytics if they’re going to support care that’s based on outcomes and not on services. When they agreed to sit at the table and put aside their competitive issues, it started to change the entire industry’s thinking,”  said Charles Jaffe, MD, PhD, CEO of HL7 International, the organization in charge of nurturing FHIR and other healthcare data standards.

Through a FHIR-enabled data activation platform, ACOs can:

  • Refer and enroll Medicaid patients in vetted community resources.
  • Drive targeted care management programs around hypertension, obesity, diabetes, asthma, and other chronic conditions.
  • Evaluate the performance of its ACO participants or its ACO providers.
  • Report quality outcomes to the state / MCOs with a  flexible reporting module.
  • Launch targeted mass outreach campaigns to bring in patients for preventive visits or screenings.
  • Identify gaps in care and track provider referral trends to prevent network leakages.
  • Triage, evaluate, and schedule virtual visits to keep the costs of managing patients down while keeping satisfaction high.
  • Use advanced analytics to increase evidence-based treatment and generic drug utilization to lower pharmacy spend.
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The FHIR-enabled data activation platform also helps members to utilize on-demand mobile-based educational materials and provides access to lab and test results, visit notes, and medical records through an easy to use and intuitive app.

Thinking about an interoperable future with FHIR-enabled Data Activation Platform 

The authorities are handing over the reins of the care journey to the patients themselves. Though Patient Access APIs patients will be able to access their data through any third-party application they choose to connect to the API and can also be used to access data through their EHR. This is to empower patients that can take this information with them as they move from plan to plan and provider to provider throughout the healthcare system.

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Drive improved outcomes with enhanced utilization and network management workflows through Innovaccer’s FHIR-enabled Data Activation Platform.

Full visibility and access to patient data for both the healthcare institution and the patient is the primary benefit of interoperability. A FHIR-enabled data activation platform will ensure an easy relay of data with stakeholders and reduce the administrative burden that tags along. As we proceed into an interoperable future of healthcare, it becomes essential for ACO members to share information. A shared pool of information will help reduce duplicative procedures and other excess costs. A FHIR-enabled data platform will help maximize revenues and improve value in care for ACOs to succeed in contracts.

To know more about how your organization can leverage a FHIR-enabled Data Activation Platform click here.


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Tags: Interoperability
Paul Grundy
How can ACOs Manage Medicaid Contracts Using FHIR-enabled data Activation platform?

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