So many get stuck in the compliance box mindset that they never realize the transformation opportunity that interoperability presents until it’s too late. Here’s an example from 2013, when, here in the United States, the ONC required the ability for each patient to have access to a patient portal that enables self-service to medical records and the ability to directly message their healthcare providers, as well as be able to support self-directed care and decision-making for providers to achieve Meaningful Use Stage 2 incentive goals. The goal was to free providers to focus on high-priority patients and empower patients to have access to their health data and resources at any time they needed without requiring them to go to their provider’s office. This unfortunately was not treated as an opportunity, but as a compliance box to check off as done. The portals were built, but nobody came. The result was it was overly complex to access and light on purposeful engagement tools that went beyond compliance requirements. Even more telling was in 2014, 33% of surveyed patients reported they weren’t even aware if they had a portal available to them, and of those that were aware less than 5% were active citing dissatisfaction as the main reason for not actively engaging with them. In 2018, an ONC poll showed that 52% of patients had access to a portal with only 28% of those accessing their records through it. Of the 24% of respondents that had access to a portal but did not take advantage of viewing their records, 76% stated they wanted to speak to the provider in person as the reason not to use the portal. This highlights the intended value of a patient portal is still not reaching the targeted audience, resulting in a checked compliance box but an ongoing missed opportunity.
The current interoperability requirementUnfortunately, the current interoperability requirement of payers and providers to give patients/members access to pricing data (Price Transparency Rule is also being perceived as a regulatory chore and not as the patient engagement opportunity it should be). Providers and payers alike can leverage this information to build comparison data that can be used to boost contract negotiations, create a center of excellence care sites, lower the overall costs of care, and improve patient outcomes.
Payer perspectiveOne would think this information has always been available and common knowledge, right? Why would you need compliance regulation for something that seems so obvious and beneficial to know? You may be surprised to learn that pricing data has always been one of the most highly guarded secrets in healthcare. Until recently, ask any payer for their charge/payment and they would rather give up the lucrative salaries of their top-paid executives before ever giving up their pricing/payment information. Why you ask? Contracts. Every payer has specific payment contracts with the providers, hospitals, and service facilities that provide care to their members. And making those differences known can have a deep impact during contract negotiations. Not to mention how varying member policies can be and what those variations mean to the end consumer/member/patient and the drastic effect it can have on the amount they are responsible for out-of-pocket. According to a review by Fierce Healthcare, MedStar Georgetown's list of shoppable services offers an example of some major differences among its payers. For instance, “the repair of superficial wounds to the neck, scalp or hands and feet has a negotiated charge of $505 for CareFirst but $4,138 for Cigna, according to the hospital's spreadsheet.” That can mean the difference of a patient paying thousands of dollars out-of-pocket compared to hundreds of dollars for the same procedure at the same facility. Shocking right?
Provider perspectiveThat explains the payer history, but what does it mean from the provider aspect now that they must also make public a list of their most common services and the charges associated with them? Hasn’t this always been publicly available and transparent? The answer to that question may or may not surprise you again, but no, it hasn’t. The “why” is very similar to the reasoning that insurance payers gave in the past. It’s complex and varies based on specific factors such as insurance contract or self-pay status, location and type of services rendered, and who provided them. Payers and providers have argued against being required to show this information stating that it is confusing and not helpful to the average patient even though the above example clearly shows otherwise. Hence, they are stuck in the compliance box mindset. Moving out of the compliance box mindset and into the transformation opportunity zone requires a shift in perspective. Anyone who has ever worked in healthcare can affirm shifting attitudes, especially when it comes to adopting a new digital strategy and openness, is not an easy pill to swallow. It requires a lot of coaxing and assurances that what seems like a shackle today is a benefit that will lead to new growth and confidence with the patients and families they have been entrusted to care for tomorrow.
How do we get there?It starts with keeping the end beneficiary in mind and focusing on their overall digital experience and improved health outcomes as the catalyst for driving new interoperability initiatives, not compliance. Instead of focusing on the difficulty and complexity that providing access to pricing transparency may bring, instead focus on the value it will provide to the patient and their families and ultimately the provider and payer as well with the right strategy taken. The value realized to the payer/provider in the form of improved care outcomes resulting from a reduction in delayed treatment due to the potential cost of care. This is one of the most immediate benefits that could be actualized if implemented with a customer-centric benefit approach. Care delayed today becomes costlier care tomorrow. Requiring advanced interventions possibly when low-to-moderate actions would only have been needed if treated sooner. The cost of delay is real and calculable not to mention the deficit to the patients quality of life when the cost is the driving factor in not seeking intervention earlier.
Pivoting the focus away from compliance and complexity to the needs of the patient/member and the value they receive from enhanced transparency and self-service digital access to information, interoperability compliance then becomes the resulting consequence of creating purposeful consumer-centric solutions.The next requirement is to have the right partner like Axway. We guide you through the most complex Interoperability requirements, as well as provide the correct tools that ensure ongoing digital transformation success and not only regulatory compliance. For example, a marketplace for accessible APIs that provides both scalable, open access and security and control. While uploading a spreadsheet and calling it a day may meet the minimum for compliance, it does nothing to create a digital experience that is meaningful to a patient/member trying to understand the full scope of their potential healthcare costs and the resulting impacts of choosing a specific provider/facility of care over another or even the difference of them seeking care at all.