CMS and ONC Interoperability and Patient Access Mandates, Part 1

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Tune into another episode of Start Your Day with Avalere. In this segment, health plan experts delve into the federal government’s interoperability requirements and how plans are navigating these changes.
“We’re talking to plans of all sizes and a lot of things are keeping them up at night. Not only are they trying to deal with the pressures of engaging their members and employees during COVID-19, but also trying to figure out the question of time and resources.” Eric Sullivan


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
Eric Sullivan , Senior Vice President, Innovation and Data Strategies, Inovalon
For nearly three decades, Eric has been leading data-driven innovation solutions, products and partnerships in a variety of healthcare domains from health systems, national and regional health plans and healthcare consulting and software organizations.

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, and I lead our health plans and providers team here at Avalere. For today’s episode, I’m joined by Eric Sullivan, who serves as the Senior Vice President of Innovation and Data Strategies at Avalere’s parent company, Inovalon. Within his role, Eric has been working closely with Inovalon’s health plan clients as they’re thinking through how they’re going to meet the expansive data sharing and interoperability requirements laid out by the federal government.

I’ll be talking with Eric about the specific challenges and opportunities that health plan executives are facing, given some of the very near-term deadlines, and where he believes the industry is headed. Additionally, he’ll share what health plan executives and others in the industry need to be thinking about as it pertains to the interoperability rules.

So, to get us started, Eric, can you provide us with more detail on what is in the interoperability rules?

Eric: Thanks, Fred. I appreciate the invitation to discuss this topic. The interoperability rule was finalized in early March, and there are three components as it relates to health plans. One is a Patient Access Application Programming Interface (API), which is that effective health plans — Affordable Care Act (ACA), Medicare Advantage, Medicaid — must expose their health plan claims and clinical data to their members through a third-party application. The second component is the Provider Directory API, which is a provider directory hosted on your website. Both components were slated for January 1, but because of COVID-19, the Centers for Medicare & Medicaid Services (CMS) pushed them to July 1 of next year. Most plans are still gearing up for a January 1 launch.

The third component is the Payer-to-Payer Data Exchange, which is still slated for and enforceable January 1, 2022, though most plans are gearing up to be ready well ahead of that. This is “simply” payers exchanging members’ prior claim history with a new plan.

Fred: Let’s turn to the conversations that you’re having with health plans. What are those “up at night” issues and the big questions they’re confronting? I’ve been involved in many of these conversations and I think it’s safe to say health plans are playing catch-up to just about every other industry in terms of digital capabilities. Some of them are coming from behind, but even for those that have been making investments, what are those big issues?

Eric: We’re talking to plans of all sizes and a lot of things are keeping them up at night. Not only are they trying to deal with the pressures of engaging their members and employees during COVID-19, but also trying to figure out the question of time and resources. CMS estimates this to be well over $1.5 million of investment in the middle of the year. So, there’s the question of, “How am I going to do this given everything else that’s occurring in the US right now, given my budget is fixed?” With 1700 pages in the combined CMS HHS rule, they’re considering who will help them get through it and make sure they don’t miss anything. Then, once they figure out the impact and who it affects, they’re questioning how they will get it done.

Fred: Given the big questions around time and resources and doing this amid the pandemic, there’s the build-versus-buy decision, particularly around developing the infrastructure to achieve this. How are plans approaching this? Are some just moving full steam ahead and doing it all in-house?

Eric: It’s a great question. When you must make this decision or meet a compliance date, there is always that question of, “Can we do it ourselves?” We’re seeing a lot of variability across the roughly 340 plans that are affected by the rule. Some of the larger national plans were already at the table with HL7, which is the industry group that’s driving this for Fast Healthcare Interoperability Resources (FHIR), the data exchange approach. Outside of those 6-10 plans, the rest are contemplating how they will find experts in FHIR, and experts in a secure API bidirectional gateway.

There’s also this aspect of figuring out what build-versus-buy is. What am I really building? So, we’re seeing a lot of plans putting out RFPs. It is the plan’s way to discover what people are doing. I think they are taking these RFP responses and saying, “OK, this is what 10 different vendors are positioning to do. Could we even try this ourselves in a very compressed timeline?”

There is this discovery of what it even means to be ready, assuming you don’t have lawyers that can read through and digest the 1700 pages. So first they must understand what it is, and then determine whether they can build it themselves. I imagine most plans outside of that small few are going to decide to find a technology partner to move this forward.

Fred: It sounds like many of the plans will be going down some version of that “buy” path in terms of partnering with a vendor. What is your take on what those health plans need to be considering as they’re evaluating technology partners?

Eric: We’re seeing the same five concerns across plans of all sizes—the 500-member plan and the 5 million-member plan.

As you’re looking at these partners, you’re first trying to understand how they can help explain which data is needed. We call it the discovery phase: Help me discover what it is that I need to do and what data I need to have. Then, can you help me stay on top of any changes that arise? We don’t have time as a health plan to be paying attention to every little nuance that CMS or ONC release.

The data ingestion topic also comes up in every discussion I have with our partners: Help me understand how you’re going to integrate the data. How are you going to ensure that it maps to the two formats that are required— CARIN Blue Button® Framework and Common Payer Consumer Data Set (CPCDS) and United States Core Data for Interoperability (USCDI), which are effectively claims and clinical data sets? How are you going to ensure that it gets there within 24 hours of being available, which is the CMS requirement?

Security is the third concern: How are you going to help us ensure that the application, whether it’s a Fitbit or some unknown app, is not someone in their basement trying to hack our data? It’s validating the security model for the app and authenticating the consumer.

The fourth concern is, what is your Fast Healthcare Interoperability Resources (FHIR) expertise? You need to have real-world experience in an API gateway where you’re exchanging data in real time for FHIR. Help us understand how you’re going to do that in such a short timeframe.

The last part is the overall experience: What is the experience for us as a payer? What visibility do we have into the operational side of this, ensuring that we’re compliant with that 24-hour CMS requirement? And what is the customer experience?

Fred: I’d love to circle back to that first item. This is an unfair question, given the reams of pages tied to these rules, but knowing that several of the folks listening to this podcast are not going to be steeped in data and the IT side of the health plans, can you give a sense of what data health plans are going to be expected to share? Can you shed some light on the extent of this, knowing that there is still a lot of gray area around it?

Eric: There is definitely gray area. We are looking at this and helping our plan customers get through this by grouping the data into three types.

You have claims, but it’s more than what you’re getting today. There are additional fields, elements different from the common payer data set. We need to help them understand we are using this data for, say, your Healthcare Effectiveness Data and Information Set (HEDIS) reporting, but there are additional data components. So, getting all the claims and all the attributes that can be expected in an Explanation of benefits (EOB)-type response. An EOB is much more detailed in nature than a typical claim set for a quality measurement. So, the claim side enters the capitated data. All the capitated vendors, whether it’s pharmacy, lab, etc., could be a whole network that’s sub-capitated. All that data needs to be part of this. So, both claims and capitated is one big bucket of data. Do you have your finger on all that data, and, as CMS describes it, are you maintaining that data in-house?

The clinical side, which is the third big bucket, is US Core Data (USCDI). Outside of lab results, are there other clinical data sets that you have in-house? A lot of our payer partners are getting spreadsheets from large hospital system partners that have biometrics like blood pressures they’re providing to help quality measurement. That’s fair game. If you’re getting and maintaining clinical data like vitals and immunizations, or downloads from the state immunization registry, that is fair game.

It’s getting an inventory of all the claims, capitated, and clinical data that you have in-house and making sure you have all that data available and closing any gaps. Also, you need to extract that data and make it available within 24 hours. That part is going to be a challenge.

Fred: Yeah, it is a heavy lift. As a teaser for an upcoming podcast, we’ll be delving into that question of what CMS is expecting and how stringently will be they be enforcing this. To your point, there’s a lot and it needs to be made available very quickly and seamlessly. So, Eric, to close out our conversation on this podcast session, I would love to get your take on what health plan executives are overlooking.

Eric: That’s a great question. Outside of what we hit so far in terms of just getting the data right, plans need to pay attention to the fact that there’s gray area. There are parts of the rule that are not fully fleshed out in terms of how to handle medical record documents. PDFs of medical records, for example. Are those fair game?

We’re seeing a lot of plans putting off the Payer-to-Payer Exchange, but that’s something that is going to require work. We want plans to be thinking about all three legs of the rule, including the Payer-to-Payer Exchange.

Frankly, I think there’s a whole other aspect of this which opens a new channel for payers to engage consumers where it works, whether it’s on their cell phone, their Fitbit app, or whatever the application. So, how do you think about that from a strategy perspective? How do you leverage this to go beyond rule requirements and start using this channel to do the things that have been hard to do in the past? Now you have a way to communicate with your members directly on their device. How do you maximize that value?

Fred: Perfect. Well, Eric, thank you so much for joining me for today’s discussion. I want to thank everybody who is listening in to our session, which is part of Avalere Health’s Essential Voice podcast series. If you want to learn more, please stay tuned for more episodes, and visit our website at

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