CMS and ONC Interoperability and Patient Access Mandates, Part 2

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Tune into another episode of Start Your Day with Avalere. In this segment, health plan experts delve into the strategic opportunities the federal government’s interoperability requirements present and consider which mandates might be coming down the pike.
“The interoperability rules should be a catalyst for real change in how plans interact with their members and encourage them to know more about their own health.” Julie Barnes, Maverick Health Policy


Fred Bentley , Managing Director, Center for Healthcare Transformation

Fred Bentley advises clients on health delivery and payment innovation, providing analytic and strategic insight on issues related to the delivery of care.

Guest Speaker
Julie Barnes , Founder and Prinicpal, Maverick Health Policy
Julie Barnes is a health care policy expert with years of experience helping the private sector navigate federal government activities that impact the health care system; Ms.

This interview was originally published as a podcast. The audio is no longer available, but you can read the transcript below. For updates on our newly released content, visit our Insight Subscription page.


Fred: Hello and welcome to another episode of Avalere Health Essential Voice in our Start Your Day with Avalere podcast series. My name is Fred Bentley. I am the Managing Director for Avalere’s Center for Healthcare Transformation and, pertinent to this discussion, I oversee our health plan IT strategy.

Today, I’m delighted to be joined by Julie Barnes. She is Founder and Principal of Maverick Health Policy. Julie is an attorney by training but has been deeply involved in health IT issues since her days as a Capitol Hill staffer. She has served as a policy analyst working within health plans and is currently an advisor to organizations ranging from health plans to associations and other stakeholder organizations in the healthcare space focused on the new Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC) interoperability rules.

I’m going to be asking Julie about the opportunities associated with these new investments, even as the industry is laser-focused on ensuring that plans will be compliant with these rules, and what future requirements might look like.

As a refresher, there are three pillars associated with the interoperability rules. There is the patient access application programming interface (API) that enables members to access health plan data, and an online provider directory that’s routinely updated. Those capabilities must come online by July 1, 2021. Following fast on the heels of those is the requirement around payer-to-payer data exchange, which is exchanging claims and clinical data between payers. That will be required as of January 1, 2022.

Today, I want to get a sense from Julie as to what the strategic opportunities presented by these mandates are, and then help you, the listeners, understand what’s likely to be coming down the pike.

So, Julie, given your unique vantage point, what is your take on the goals of CMS and ONC with these ambitious interoperability and patient access mandates?

Julie: Well thanks, Fred, for having me on today. I’m so glad to be with you. CMS and ONC have lofty goals for these new interoperability requirements. The overarching goal is to provide Americans, their doctors, and the organizations that are helping them with healthcare services and products with quick, free access to their entire healthcare history. So, for the first time in our country’s history, everyone can get their own healthcare information through an app on their smartphone. It should be as transformative as the ATM was for the banking industry. Someday people will say, “Hey, remember when it was really hard to get your medical records? That was so terrible.” The interoperability rules are trying to make that a thing of the past.

Fred: What role do policymakers expect health plans to play in achieving those objectives?

Julie: Health plans have a unique role because they see where an individual has been beyond one hospital or doctor visit. Health plans are paying for services and products at pharmacies, clinics, and specialists, and they pay for lab tests. Health plans can track the full universe of somebody’s healthcare journey.

The agencies are asking health plans to not just set up a portal with their own health plan information, but to actually tell people their full medical history—who they saw, when they saw them, for what condition, and any other clinical and claims data the health plans know about.

Fred: To what extent are plans ready to step into that role in terms of facilitating data exchange and empowering members?

Julie: Health plans are being asked to do something so new for them. Healthcare providers have been dealing with Meaningful Use requirements with their electronic medical record systems for years. They hired vendors to help them with the technical data standards and things that were unnatural for healthcare providers. Health plans didn’t do any of that. They have customized systems that were built for the primary purpose of paying claims. They’re cryptic and full of information that’s just about invoices and payments. None of those systems were built for regular people to understand their medical history.

Now, without much warning, payers will be expected to make patients’ data available electronically through a series of channels like mobile apps and allow for secure access to data through interoperable APIs. Many payers are uncertain how to meet those requirements, which is not great because the clock is ticking.

Fred: In our previous podcast, we discussed the technological capabilities and systems expertise these health plans need to develop. The technical aspects are significant, but I’d love to get your perspective on what these plan executives and leaders tasked with getting the systems up and running and compliant are overlooking?

Julie: The timing of these rules is really bad. With the pandemic, it’s not a great time to be thinking strategically. Even the visionaries among us are really struggling. Most of the discussion to date is about how plans can comply with the rules and get it over with. This technical jargon reads like an iPhone manual. It’s not easy.

The emphasis has been on what this means and who we hire and how we do this, when instead, this should be an opportunity for plans to improve their relationships with their enrollees in the provider networks. The interoperability rules should be a catalyst for real change in how plans interact with their members and encourage them to know more about their own health. Health plans could help people understand how to be better, smarter consumers of healthcare services and products, and how to lead healthier, productive, happy lives. But health plans don’t think of themselves that way.

It would be better if we focused less on technical compliance and more about how these interoperability rules can be a game changer.

Fred: Can you provide some examples of how these new capabilities could benefit plans? Do you know of specific health plans that are thinking strategically in this space?

Julie: Plans will not be sorry that they invested in these new capabilities. It’s going to be the cost of doing business in the future. The plans that are already invested get that, but everyone needs to grasp that the business efficiencies that they will gain with this technology will be worth it.

There are a few plans that are ahead of the game. Some have been involved with strategies and data standard development organizations all along. The one that comes to mind is Cambia Health Solutions, the regional Blue Cross Blue Shield plan out of Portland, Oregon, because I worked there. They were a founding member of the CARIN Alliance, which is a public-private collaboration that’s been spearheading interoperability plans for several years. Cambia has this mindset of being a consumer navigation tool with its data, but they have a few bells and whistles as well.

One tool is HealthSparq, which compares physicians and costs for consumers. GoodRx is famous for cost comparisons of drugs. Another one, called MedSavvy, compares the effectiveness of drugs. Those are the kinds of bells and whistles that can accompany these interoperability APIs, which I think are huge differentiators for plans.

Health plans that were involved in the HL7 Da Vinci project, which is the private sector industry leaders and the health IT technical experts that are working together on HL7’s FHIR standards for healthcare data exchange, are ahead of the game. Those are the famous plans—Cigna, Humana, Anthem, United Healthcare through Optum, and visionary BlueCross BlueShield plans in specific states.

Fred: What is your perspective on the business benefits of having these capabilities? We work with health plan finance executives and CFOs and they are going to be asking whether this is this really a strategic differentiator. Is there evidence that serving in this new role in terms of member engagement and education and data-sharing drives growth?

Julie: That’s the million-dollar question, and I think the evangelists would say, absolutely. I’m a little bit more of a skeptic. As excited as I am about the possibilities, I think that the jury is out. We’re building the proverbial football stadium, but whether people want to go to the football game is yet to be seen.

It’s important to create a whole set of solutions, not just a data dump. This must work for consumers and create something that becomes a demand. When the iPhone was developed, nobody needed it, but now we can’t live without it. I think we’re looking at something like. It could fall flat if not done well.

Some of the health plans I mentioned earlier are positioning themselves to hit it out of the park. They see it as a competitive differentiator. We only have one example right now, which is the Blue Button 2.0. The best we can do is look at who has done this before. The test is, can you do this commercially for everybody everywhere with their varying levels of interest in education and everything else. That’s just unknown. We’ll have to see how people pick this up, especially our elderly sector of society that doesn’t understand how to deal with the medical delivery system without seeing humans. That is an entirely different mindset from the generation that looks everything up.

Fred: The fact that there are so many new consumer-focused healthcare applications emerging daily suggests that there’s an appetite there. There is a role for health plans, given all the capabilities they have at their fingertips that smaller startups don’t.

Julie: That’s exactly right, but health plans need the tech help and the tech need the healthcare help. CMS and ONC decided to capture health plans in this interoperability game because nobody has the 360-degree viewpoint that health plans do. Data from a hospital doesn’t tell you about the drug the patient ordered from a mail-order pharmacy, but the health plan can. I do think the future is with the kids, so we need to pay attention to what they care about.

Fred: Speaking of the future, what can we expect in terms of future requirements, future regulations coming from CMS and ONC in the interoperability space? There are some big ones out there that we’ve been talking about, but they’re not stopping there.

Julie: CMS and this administration tend to preview what they’re going to do next. In the proposed interoperability rules, they had a laundry list of requests for information (RFIs) so they could get feedback from stakeholders ahead of the 7 or 8 different interoperability rules that they intend to propose. You don’t usually have this flashing neon light in regulatory land. In March 2019, they said, we intend to issue rules about information sharing between payers and providers. So, a direct moment for APIs. There’s also interoperability for the dual eligible population that’s reportedly coming. There are post-acute care setting considerations. That’s just the tip of the iceberg. Patient matching is huge and should have, frankly, already happened, but there’s just such dissonance about what to do about it. It is on the horizon. Price transparency is practically here and that’s going to be about what data must be live for people, which is a consumerism issue. People probably want to know about that most of all.

There is a scalable component to this that is hard to comprehend. I think that’s the hardest part of the whole thing.  Once you get done with the basics of opening up interoperability, there’s an endless possibility of what’s next.

Fred: And we have this little presidential election coming up. As you alluded to, the Trump administration has their approach, which could look different under Biden. Although, they might step on the gas with these rules and there would be some continuity in terms of the mandates.

Julie: Oh, at least continuity. I think that if former Vice President Joe Biden becomes President Joe Biden, the gas-stepping is likely because of his personal considerations and experiences. His son died tragically, and they struggled to get his medical records where they needed to go. He has talked about it and never forgotten it. It’s an important truth that people struggle to get their medical records where they’re needed. So, the information blocking is huge. It’s really part of this whole plan that was put into place under the Obama administration. So really, the Obama administration has been cheering on the Trump administration’s acceleration of it with gusto. It’s hard to believe that anybody could go as fast as this administration has on some things, which is not usually the way in the regulatory world. I don’t think there will be space, air, or light between the administrations’ philosophies.

Fred: That’s great. Julie, I really want to thank you. I appreciate you joining in today’s discussion. Your insights are invaluable to our listeners. I want to thank everybody who has tuned in for this podcast and if you want to learn more, please stay tuned for more episodes and visit our website at Please also visit to learn more about Julie’s work in this space.



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