Empowering Patients through Interoperability

Empowering patients with data to make more informed decisions about their care is one fundamental step in the healthcare industry’s pursuit of improved patient outcomes. The Centers for Medicare and Medicaid Services (CMS) released a final rule (CMS-9115-F) on March 9, 2020, addressing interoperability and patient access to health data. The goal of the rule is to improve patients’ access to their health data, as well as the quality of this data, to empower them to make informed choices. The final rule includes wide-reaching provisions that impact states, managed care entities, electronic health record vendors, and providers.

As many states are currently, or will soon be, implementing modular Medicaid Enterprise Systems (MES), State Medicaid Agencies (SMAs) will need to consider and account for the impacts of this final rule on their MES transformation. Additionally, the vendor community – MES module vendors, strategic advisory vendors, Independent Verification and Validation (IV&V) vendors, and others – will need to adapt to the requirements of the rule and its implications. In our assessment, the requirements for patient access to data through Application Programming Interfaces (APIs) and the increased frequency of data transfers for Medicare-Medicaid dual eligible beneficiaries will most significantly impact SMAs.

APIs and patient data

While the API standards and requirements largely affect providers and third-party application developers, SMAs with in-flight module procurements will need to analyze their system requirements and modular architecture for impacts. The final rule could have implications for integration platform, data warehouse and operational data store, provider module, and beneficiary module projects.

The final rule requires access to three key types of data:

  • By January 1, 2021: API access to patient claims and encounter data from January 1, 2016, onward
  • By January 1, 2021: API access to provider directory data
  • By January 1, 2021: API access to formulary data 
  • By January 1, 2022: Payor-to-payor exchange of clinical data through APIs or a health information exchange (HIE), when the patient requests it. CMS will not take enforcement action against certain payors for the payor-to-payor data exchange provision of the May 2020 Interoperability and Patient Access final rule until future rulemaking is finalized.

These requirements apply to Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs, Medicaid managed care plans, and CHIP managed care entities. CMS released the interoperability rule alongside a companion rule from the Office of the National Coordinator for Health Information Technology (ONC) that establishes standards for secure APIs to transmit data. These standards are critical to protecting Personally Identifiable Information (PII) and Protected Health Information (PHI).

Preparing for more frequent data exchanges

The CMS interoperability final rule also requires states to shift from monthly to daily data exchanges for Medicare-Medicaid dual-eligible beneficiaries by April 1, 2022. The data exchanges include state buy-in files and “MMA files” (named after the Medicare Modernization Act). To address the increased frequency of reporting, SMAs will need to review their current data architecture and ensure the governance is in place to provide timely, accurate data exchange.

Planning for the provisions of the CMS final interoperability rule will be critical to ensure your state is out in front of the deadlines for data sharing. Some of the impacts your organization will need to consider include:

  • System requirements development
  • Procurement evaluations
  • Solution testing
  • CMS certification requirements

States that are transforming their legacy systems to a modular MES environment may need to perform and communicate impact assessments to CMS.

Like any change of this magnitude, challenges will inevitably arise for many of the vendors and agencies involved. Proper awareness of the new requirements and how they will integrate into new MES solutions, coupled with robust planning and stakeholder cooperation, should lead to successful transitions into a more transparent and modular Medicaid ecosystem. These types of innovations in the Medicaid landscape will be significant to the provider and beneficiary populations, achieving the goals of improved data access and transparency, as well as better healthcare outcomes.

Reference Links

CMS Final Rule and Fact Sheet

ONC Final Rule