Dec 10, 2020

Reducing Provider and Patient Burden, and Promoting Patients' Electronic Access to Health Information

Seema Verma
Administrator, Centers for Medicare & Medicaid Services

Today we announced a major new proposed rule that will push the healthcare system to new frontiers of seamless data sharing. CMS, along with the White House Office of Innovation, launched the MyHealthEData Initiative. It aimed to ensure patients had access to their medical data and to advance the private, seamless flow of health data to increase the efficiency of the system and lower health care costs. Today’s rule is a part of this effort. 

Before getting into the details of the rule, I’d like to start with some brief context. When the Trump administration took over, we understood that in a world where we can communicate instantaneously with someone on the other side of the globe, or access our bank account from anywhere, it’s not acceptable that our health information capabilities remain mired in the Stone Age. In 2020, faxes should not be the primary means of records transfer.

After the previous administration made a massive investment of $36 billion dollars to get health records on electronic systems, the future seemed bright. Patients would no longer shoulder the burden of reconstructing from memory a lifetime of medical information in a moment of crisis – when a quick decision might mean the difference between life and death.

Providers would spend less time making and transcribing notes after long shifts and would have complete patient data at their fingertips, allowing them to avoid duplicate tests and unnecessary treatment. And the free flow of information would inaugurate a new era of medical innovation that would transform the face of healthcare.

Unfortunately, that future never materialized. Our reforms, aimed at finally fulfilling the great promise of electronic health records, were already historically transformative even before today’s proposal.

We started by requiring hospitals and clinicians to share data with patients in order to avoid financial penalties or obtain incentive payments. Then, we launched Blue Button 2.0, Medicare’s first developer-friendly, FHIR-based Application Programming Interface, or API. APIs are interfaces that allow two systems, or a payer’s system and a third-party app, to communicate and share data. FHIR is innovative technology that helps bridge the gaps between systems so they can understand and translate the data they received.  In this way, Blue Button links Medicare claims data to apps on beneficiaries’ phones or other devices, so they can have it at their fingertips and share it with whoever they choose.

Earlier this year, we took things to a new level. The Interoperability and Patient Access final rule requires that all health plans doing business with the federal government deliver something like Blue Button 2.0 to the 85 million patients in CMS-regulated health plans. As a result, payers must step up to the plate and share that wealth of claims data directly with patients. Claims data sheds an enormous amount of light on patients’ health histories, including medications they have received, operations they have undergone, prior providers they have seen, and all their diagnoses.

Whereas our earlier rule focused on getting health data into the hands of patients, today’s rule is distinctive and groundbreaking because it greases the data exchange wheels between different payers, as well as between payers and providers. This will close the loop on data sharing, ensuring that all parties – patients, payers, and providers alike – have ready access to patient data.

Specifically, the rule requires Medicaid managed care and insurers offering products on the Exchanges to facilitate the exchange of patient data as they move from one payer to another. While Medicare Advantage plans are not included in today’s proposals, CMS is considering whether to do so in future rulemaking.

You’ll recall that in the Interoperability and Patient Access Proposed rule, we required that payers exchange information with one another at patients’ request. Because the rule requires a FHIR-based API allowing different payers’ systems to communicate with each other, new plans will have access to a patients’ claims data almost as soon as they enroll. 

In addition, this new API can be used by payers to send patient claims, encounter data, and clinical data directly to providers’ EHRs, allowing for the seamless flow of data. As soon as a provider requests this information from plans, they will immediately have their patient’s complete medical claims data, including diagnoses, tests, medications, previous doctors, and more. For providers that take full advantage, duplicative tests, unnecessary procedures, and hazardous interactions between medications could almost be a thing of the past.  

In effect, the rule would add another layer of communication to our earlier final rule that gave data directly to patients. If for whatever reason, a patient did not have their data at a particular visit, their providers should be able to pull it up instead.

Finally, the proposed rule tackles one of the foremost problems for providers, plans and patients alike: prior authorization. Prior authorization is an administrative process for providers to request approval from payers to provide a medical service, prescription, or supply. This process takes place before a service is rendered.

While it has a role in utilization management and fraud and abuse prevention, prior authorization has become onerous for physicians. When CMS launched its Patients over Paperwork Initiative and solicited input from providers about the most burdensome administrative elements of their job, it was consistently near the top of the list.

Prior authorization processes can drain significant time from the very purpose of medicine – caring for patients – in favor of often mindless nitpicking and wrangling with distant bureaucracies. The interminable delays and back-and-forth make prior authorization the top cause of physician burnout.  These processes can delay needed care for patients who will sometimes unnecessarily pay out of pocket or even forgo important care just to avoid the inevitable slog.

This element of today’s announcement is the result of numerous listening sessions with plans and providers aimed at crafting a new process that balances the need for greater efficiency and consistency in prior authorization with its important role in preventing fraud, abuse, and unnecessary expenditures. We look forward to reading public comments, but we believe the rule strikes that balance.

The proposed rule requires certain payers to build another FHIR-based API that would allow providers to know in advance what documentation is needed for each different health insurance payer. Still another API would be built to allow providers to send prior authorization requests and receive responses electronically and within their existing workflow, eliminating the need for phone calls and faxes. This would streamline the documentation process for the entire system and allow providers to send prior authorization requests and receive responses directly from their electronic systems.

The rule would also reduce the maximum amount of time for payers to approve a prior authorization request to 72 hours for urgent requests and seven calendar days for non-urgent requests. Any patient who has spent weeks anxiously waiting for a payer to come to a decision on an important procedure will understand how significant this policy will be.

Payers would also be required to provide a specific reason for any denial, which will allow providers some transparency into the process. To promote accountability for plans, the rule also requires them to make public certain metrics that demonstrate how many procedures they are authorizing or denying.  This unprecedented level of transparency can aid patients when they select their health plan and providers as they negotiate with plans.

Between the final rule earlier this year, which will go into effect on January 1st, and this proposed rule, virtually every patient, provider, and payer in the healthcare system will soon enjoy smooth, hassle-free access to patient data. 

For patients, there will be no more wrangling with prior providers and locating ancient fax machines to take possession of one’s own data; for providers, there will be no more piecing together patient health histories based on incomplete, half-forgotten snippets of information pried out of the patients themselves; for payers, this is the first step towards building the important data sharing systems we need to move towards value.

In short, this represents a watershed moment. Today, we are taking a historic stride towards the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system.

 

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