Are your Payer CDI Projects stuck between the Peak of Inflated Expectations and the Trough of Disillusionment?

Author:  Smile Digital Health |  Published:  September 23, 2020

With spiraling costs and lackluster health outcomes, there is widespread recognition that the US health industry needs to move towards incentivizing performance over volume. To realize this, US payers will need to accelerate interoperability between themselves and other healthcare stakeholders. 

This puts payers in a challenging position. They face employers worried about ballooning plan costs and members who expect high quality digital experiences on par with those offered by other industries like travel, banking, and retail.

Meanwhile, the CMS and ONC have mandated that payers use open APIs to share patient data with consumers (via 3rd party apps) and other payers. 

These converging forces have lent a renewed urgency to payers’ Clinical Data Integration (CDI) initiatives, as outlined in a recent Gartner report, Hype Cycle for US Healthcare Payers, 2020 (Gartner subscription required).

The report states:  “clinical data integration (CDI) for payers enables the acquisition and normalization of patient data from an electronic health record (EHR) system or health information exchange (HIE), as well as the integration of that data with payer systems and business processes.”

In the past, acquiring and normalizing clinical data hasn’t been a priority for payers, and most haven’t approached it systematically. The report states, “the acquisition of clinical data is a critical capability for U.S. healthcare payers with potential high, near-term business impact. The most urgent use cases from a payer perspective are:

  • Regulatory Compliance — Conforming to the rules from CMS, OCR and ONC compels payers (along with any providers with which the payer operates) to share health data shortly after receipt of the information.
  • Risk Score Optimization — Increasing documentation of medical risk such that it is accounted for in the risk adjustment mechanisms of certain lines of business such as the Hierarchical Condition Categories (HCCs) submission in Medicare Advantage and public exchanges.
  • Quality Measurement — Improving the Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Star Rating measures by supplementing administrative data with data from EHRs.”

For payers, these developments also come with some good news. The CMS and ONC interoperability regulations are providing many payers with the initial impetus for CDI, but they’re simultaneously making it more achievable by mandating that payers all start using HL7® FHIR®. Paired with increasing vendor and provider adoption of FHIR, all players in the health data value chain finally have a common data standard for the exchange of both clinical and administrative information—making CDI more attainable than ever. 

Why is HEDIS Important to Payers— and Why is HEDIS moving to FHIR?

HEDIS is an important quality measurement score in use by over 90% of US health plans, measuring performance across over 90 measures and six domains of care. In a consumerized healthcare market, patients and employers have an increased ability and willingness to “shop around.” When comparing plans, HEDIS scores offer consumers a way to compare different plans on the same terms. For payers, this makes strong HEDIS scores an important competitive differentiator. 

However, HEDIS is much more than just a marketing tool. It’s a key factor in achieving National Committee for Quality Assurance (NCQA) accreditation, which is in turn required for many payer business lines, especially Medicare Advantage and Medicaid plans. And in practice, even if not technically a requirement, many large commercial customers like businesses or institutions won’t consider a plan that isn’t accredited by NCQA. 

Beyond these factors, HEDIS scores also impact Medicare Star Ratings, another important quality measure which is tied to CMS financial incentives. Even a seemingly minor increase, like going from 3.5 to 4 stars, can result in hundreds of dollars in extra funding per member.

Another factor that payers should consider: the NCQA has announced a draft plan to use FHIR for HEDIS measurements starting in measurement year 2022 (for reporting in June 2023), with FHIR pilots beginning in 2020. According to the NCQA, this is to align quality measurement with broader industry trends and with other healthcare stakeholders already leveraging FHIR. 

The upshot is that FHIR is continuing to gather steam both for HEDIS and in terms of interoperability use cases generally. Payers who move decisively to implement a FHIR-based data platform with scalable, enterprise class CDI capabilities will be positioned to stay ahead of the hype cycle and gain significant competitive advantage. 

An Enterprise Approach to CDI

To get the most out of CDI, payers need an enterprise-wide strategy to integrate clinical data with claims data in a centralized location. From here, it can be leveraged by multiple payer systems to improve HEDIS scores, improve risk adjustment reporting, or produce analytics-driven insights for other business processes. 

In Hype Cycle for U.S. Healthcare Payers, 2020,  where Smile Digital Health is listed as a Sample Vendor, Gartner states  “this Hype Cycle provides critical input for strategic planning by tracking the maturity levels and adoption rates of emerging payer technologies and approaches. U.S. healthcare payer CIOs should use this research to plan their investments to optimize and transform.”

How Smile Digital Health Can Help

Smile was also identified as a Representative Vendor “offering solutions tailored to achieve compliance with the CMS rule” in Prepare for CMS Interoperability and Patient Access API Compliance for U.S. Healthcare Payers. To find out more about how Smile can help payers comply with CMS and ONC interoperability requirements, get started by taking a look at our solutions for payers

Our world class team of FHIR experts is here to help with your strategic CDI initiatives. Connect with us and see how our experienced implementation team and best-in-class FHIR data platform can accelerate HEDIS optimization efforts, patient access, data unification, and more. 

Gartner “Hype Cycle for U.S. Healthcare Payers, 2020,” Mandi Bishop, et al, 5 August 2020 

Gartner “Prepare for CMS Interoperability and Patient Access API Compliance for U.S. Healthcare Payers,” Mandi Bishop, 15 June 2020 

Gartner does not endorse any vendor, product or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s Research & Advisory organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

FHIR® is the registered trademark of HL7 and is used with the permission of HL7.