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Radar On Market Access: Interoperability Mandate Could Be an Opportunity for Payers

Posted by Peter Johnson on Apr 8, 2021


Payers should look at the looming interoperability mandate as a chance to gain a lasting advantage over their competitors, according to two health care information technology (IT) experts.

In a March 26 webinar hosted by America's Health Insurance Plans (AHIP), IBM Vice President Michael Curry of Watson Health and Jeff Rivkin, research director for payer IT strategies at IDC Insights, said payers should do more than meet the minimum interoperability standards, AIS Health reported.

"It's just the tip of the iceberg. We're going to see a lot of data exchanged. And if you don't have a fairly robust platform to be able to do that, you're going to hurt next year, too," Rivkin said.

Starting July 2021, HHS will require insurers that sell Medicare Advantage, Medicaid and CHIP managed care, and Affordable Care Act exchange plans to launch an application programming interface (API) that will allow patients to access their complete medical and claims history on demand along with a continually updated provider directory. Payers must also make all of their patient and claims data available to other insurers on a payer-to-payer data exchange, which must be in place by January 2022.

Rivkin said insurers should think about the interoperability mandate and the mandate to release pricing information as the same project. Starting on Jan. 1, 2023, health plans must offer members online shopping tools that allow them to see the negotiated rate between their provider and their plan, as well as a personalized estimate of their out-of-pocket cost for 500 of the most shoppable items and services.

"We're all in the middle of those implementations, but there's a huge downstream potential for that data," Curry explained. He says the pandemic-spurred telehealth boom has accelerated changes in consumer expectations.

"The consumer side…has changed a lot in how payers have to think about their relationships with clients," Curry added. Consumers, he said, now expect accessing health care to be more similar to "buying something on Amazon."

"Amazon and those like it have raised the bar from the consumerism perspective," Rivkin said. "Now, you've got a significant number of people in the individual market switching because they shop for price. The idea that retail companies have had for years of loyalty and stickiness…is now relevant to health insurance."

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Topics: Industry Trends, Data & Analytics, Payer