Health Care’s Data Revolution: How Interoperability Is Reshaping Payers, Providers, and Patients
In today’s rapidly evolving health care landscape, the ability to seamlessly exchange data is more critical than ever. As the industry shifts toward greater interoperability, the role of standardized data exchange—particularly through Fast Healthcare Interoperability Resources (FHIR) APIs—is transforming how payers and providers operate. In this interview, Nolan Kelly, chief revenue officer at 1upHealth, discusses the shift from a business-to-consumer (B2C) to a business-to-business (B2B) data exchange economy, the impact of new Centers for Medicare and Medicaid Services (CMS) regulations, and the opportunities and challenges facing health plans, providers, and patients.
Please share your name, title, and a brief overview of your professional history.
Nolan Kelly: Nolan Kelly, chief revenue officer at 1upHealth. I’m enamored by the necessary changes required in the data exchange infrastructure in health care. I’ve spent my career in sales and marketing roles, always focused on growth through high-impact solutions that challenge the status quo. I was fortunate enough to work at Blue Cross Blue Shield of Massachusetts, to lead the build of PatientPing’s (now Bamboo) national care management network, and now to champion a standards-based, big-data platform at 1upHealth. The internet economy—through data standards and technology—has transformed nearly every other industry, and now health care payers and providers must accelerate adoption to keep pace.
What are the potential benefits and challenges of the upcoming shift from a B2C to B2B data exchange economy for Medicare Advantage members and health plans?
Kelly: Health plans were required to stand up and manage Fast Healthcare Interoperability Resources (FHIR) application programming interfaces (APIs) for patient-mediated access in July 2021. That was a noble regulation, but it didn’t enable plans to operate more efficiently in their clinical, administrative, or quality initiatives. With the Centers for Medicare & Medicaid Services (CMS) 0057 regulations, health plans are now required to have FHIR APIs available for population-level data exchange with other health plans and providers through the Payer-to-Payer API and the Provider Access API. These APIs have the potential to create a real advantage for the health plans who think beyond “check the box” compliance.
Understanding quality measurement, population health, financial performance, utilization of benefits, leveraging AI and other analytic advancements, and making payer-provider and vendor relationships operate more smoothly are just a few of the very real, near-term benefits of the move to standards-based APIs between health plans and providers.
How will Payer-to-Payer regulations affect the sharing of member data between health plans, and what are the implications for providers and patients?
Kelly: In today’s environment, if a member moves from one health plan to another, they leave all their claims and clinical history behind and start with a clean docket at the new health plan. This lack of data continuity can create situations in which a health plan doesn’t understand how or why a member is receiving certain care (medications, authorizations, step-therapies, full care teams, and more). On the health plan side, when a new member joins a plan, there is often a strategic scramble to procure data to understand a risk profile for that member. Understanding risk can impact risk adjustment processes, provider recommendations, and the promotion of care management or wellness programs offered by the health plan. This current model brings with it a tremendous amount of inefficient operations and spending.
With Payer-to-Payer data exchange, a health plan will be able to acquire a member’s historical claims and clinical history from the prior plan. Health plans that implement technology and processes to immediately analyze that data and turn it into actionable insights (risk adjustment, network recommendations, improved member experience options, etc.) will be the clear winners. This has a significant potential impact on plans, providers, and patients/members.
In what ways may the move towards greater interoperability in health care lead to improved quality of care and reduced costs?
Kelly: This question is really about sustainability and solvency. Look at the headlines around Medicare Advantage. Health plans are going out of business. Stock prices drop by hundreds of millions of dollars overnight as earnings are released. The stark reality is that the industry is changing quickly, and there will be winners and losers. In order to be on the winning side of transformation, health plans must open data flows into and outside of their organization. Payers and providers need to have real-time, on-demand access to claims, clinical, and other data to perform their roles. Vendors cannot wait for flat-file proprietary data dumps every 30 to 60 days. The rest of the internet economy operates in a data on-demand world—consumers expect it. Interoperability can’t be just a buzzword; it’s an enabling principle in the future of health care.
Are there any other key points you’d like to leave with our audience?
Kelly: The technology that can solve health care’s interoperability problems already exists. CMS has done a stellar job kicking the pinwheel with regulations. It’s time for the free market to take over. Health plans must demand FHIR API data access from the electronic medical records (EMRs) of the providers who care for members and seek payment. The broad EMR vendor community, including all household names, need to make Bulk FHIR APIs a reality. Providers must be able to act on real-time data from health plans to help close gaps, avoid duplicative care, and see around otherwise blind corners. The time is now.
