Info Blocking

How does the information blocking rule affect payers?

Will it help accelerate the shift to a pay-for-performance model?

By Meghan Franklin
March 11, 2021

When the Office of the National Coordinator for Health Information Technology (ONC) Final Rule was released, payers were not included in the list of actors who would be held accountable to info blocking regulations. Instead, the ONC Final Rule (also called the info blocking rule), focused on requirements for health IT developers, health information networks/exchanges, and providers.

The CMS Final Rule, however, detailed three requirements specifically for payers:

  1. Patient Access Application Programming Interface (API): Payers must have the infrastructure in place for members to access certain administrative and clinical data via a third-party application of their choice.
  2. Payer-to-Payer Data Exchange: Payers must be able to exchange certain clinical data with other plans as patients change carriers and request their data move with them.
  3. Provider Directory API: Payers must have provider directory information available via API.

So, while the CMS Final Rule has clear implications for payers, I asked physician, health information technology expert and former UnitedHealthcare Clinical Services Chief Health Information Officer Anupam Goel, MD, MBA: Does the info blocking rule affect payers at all?

Info blocking’s implications for payers

In short, Dr. Goel said that information blocking does not appear to be a major concern for many payers. He said although payers are working furiously to develop the technical capabilities to enable data sharing mandated by the federal government, the information they are being asked to share does not threaten any of their current business models. Sharing claims and associated cost information will not provide enough information to help patients make more cost-conscious decisions.

Please note: If a payer or a provider employed by a payer meets the 45 CFR 171.102 definition of health care provider, health IT developer of certified health IT, or health information network or health information exchange, that payer would be considered an actor for information-blocking purposes. See the Office of the National Coordinator for Health Information Technology’s (ONC) tip sheet that defines each type of information blocking actor.

Since the info blocking rule doesn’t extend broadly to patients and payers, Dr. Goel said that health plans are instead focused on preparing for the upcoming Transparency in Coverage Final Rule (CMS-9915-F).

About the Transparency in Coverage Final Rule

The Transparency in Coverage Final Rule states that health insurance issuers must make available, starting Jan. 1, 2022, three separate machine-readable files with monthly updates through an internet-based self-service tool:

  1. Negotiated rates for all covered items and services between the plan and in-network providers
  2. Historical payments to, and billed charges from, out-of-network providers
  3. In-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level

Starting Jan. 1, 2023, health insurance issuers will be required to provide personalized out-of-pocket cost information and the underlying negotiated rates for all covered health care items and services, including prescription drugs-- limited to an initial list of 500 shoppable services. The remaining services would have to be posted starting Jan. 1, 2024.

Issuers that empower and incentivize consumers through plans that encourage consumers to shop for services from lower-cost, higher-value providers, and that share the resulting savings with consumers, can claim “shared savings” payments in their medical loss ratio calculations.

In 2022, health systems will have more visibility into what payers have negotiated with nearby health systems for any given procedure. This information will be more valuable to patients and competing health systems than the “full charges” that hospitals have posted since Jan. 1, 2019.

“Payers may get pushback from health systems that will now be able to see that hospital A is getting a better reimbursement rate than hospital B for a specific procedure,” Dr. Goel said.

Info blocking and the shift to value-based care

With increased interoperability and easier access to data, I asked Dr. Goel if he thought third-party apps would help drive a shift to where patients are really shopping around for the best value in healthcare. If patients could easily see clinical outcome and cost data, what would that do?

Dr. Goel believes the shift isn’t going to come from third-party app innovation. “Patient demand will need to drive the innovation for it to be sustainable,” he said.

“Today, most patients do not feel comfortable making cost-quality tradeoff decisions on their own. They trust their providers’ recommendation of where to receive care. Providers typically know how well specific providers perform procedures within their health system, but they may only have some insight into how other providers perform procedures elsewhere. Ideally, providers can and should do a better job of initiating and supporting value-based care conversations with their patients, including short- and long-term success rates, recovery times, complication risks and costs,” Dr. Goel said.

“Colon cancer screening is a great example. Most providers will just write an order for a colonoscopy and hand it off to the patient, essentially saying, ‘Good luck!’” But, one in eight colonoscopies leads to a surprise bill. Wouldn’t it be great if providers would say, ‘This procedure could cost you $4,500 at this facility; I know a few places nearby that could do the procedure for $3,500 for the same level of quality,’” he said.

Dr. Goel believes initiatives like the information blocking rule will support patients and caregivers looking to obtain the highest-value healthcare regardless of the health system.

Ideally, medical homes would triage out to specialists/centers where they believe their patient will get the best treatment possible for their particular condition at the best value. In most cases, that’s just not happening.

“Most health systems value patient retention over clinical outcomes that are meaningful for patients. Until the dominant payment model shifts from pay-for-service to pay-for-performance, there will not be much incentive for organizations to identify and utilize centers of excellence,” Dr. Goel said.

Hopes for info blocking

As the info blocking compliance date approaches, Dr. Goel said he hopes health systems will consider going above and beyond the letter of the rule. Addressing patients’ frustration about moving records to other health systems could be a competitive advantage in many healthcare markets.

“I hope more and more health systems will ask: If I were a patient seeking high-value care, what information would I need to make a good decision about where to get that care? If I were patient seeking high-value care, what information would I need to be able to receive my care anywhere? And, going a step further: Where can I go where I won’t risk getting repeat, unnecessary testing?” he said.

Dr. Goel is hopeful that increased access to data will not only benefit patients, but also our healthcare system as a whole. “We need to have more granularity around metrics that matter to patients,” he said. “For many conditions, we don’t even know what quality care looks like.”

Improved access to data and increased interoperability are both steps in the right direction.

About the expert:

About the expert: Anupam Goel, MD, MBA, is an internal medicine physician and health information technology (health IT) expert who believes health IT can support evolutionary change in the American healthcare system. Having worked for health systems and as Clinical Services Chief Health Information Officer for UnitedHealthcare, Dr. Goel understands the challenges that various healthcare sectors face. He believes that health IT and a shift to value-based payment arrangements has the power to markedly increase healthcare’s value from multiple perspectives.

About the writer: Meghan Franklin is a writer and strategic communicator with an M.A. in Rhetoric and a deep background in healthcare. As a former healthcare IT project manager and communications specialist at one of the nation’s leading children’s hospitals, she loves delving into healthcare topics. She values working with individuals and organizations on a mission to do something good.

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