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Unexpected Consequences of the Cures Act for Health Plans — and How to Prepare


New interoperability rules will soon empower individuals to access healthcare data from their smartphone.

New interoperability rules will soon empower individuals to access healthcare data from their smartphone. It’s a move that presents tremendous opportunities for health plans to strengthen the member experience, reduce costs and improve quality. It also could leave health plans more vulnerable to competition unless they shore up data integrity and their consumerism strategy.

The 21st Century Cures Act sets standards for secure and seamless exchange of data among payers, providers and consumers. The Cures Act gives health plans significantly greater leverage in accessing clinical data and patient demographic information. The ability to access and analyze the data enables health plans to improve health outcomes by pinpointing critical gaps in care and deploying resources to close these gaps. In this environment, third-party app developers could become critical collaborators with health plans, especially as plans shift from portal-only data access to applications that help members better coordinate their care and manage their health.

But when you unleash member data and make it available not just to members, but an entire ecosystem of payers, providers, and small, innovative players, the consequences could take health plans by surprise. In a recent webinar, experts shared three considerations that should be top of mind for health plan leaders in the move toward Cures Act implementation. Here are three issues they discussed:

Health plans will be on the hot seat for data integrity

As the Cures Act is implemented, health plans will become central aggregators of data, given that they hold the consumer’s claim and clinical history across providers. However, with data coming from disparate systems and in multiple formats, payers will face technical challenges tying data to the member. Often, the data won’t be tied to a member ID; instead, identifying details could be limited to the member’s name, address, date of birth, and gender. While this may seem a solid foundation for matching criteria, Tom Schwaninger, senior executive digital advisor for L.A. Care Health Plan, warns that in Los Angeles, members exist with exactly the same name, date of birth, and gender. “Even as we receive enrollment data from the state or the federal government, there will be issues with matching that data to the member and ensuring its integrity,” he says.

Health plans will face greater challenges with data integrity — and all eyes will be on them as they work out these kinks. Members will push back on the data they are seeing, especially as plans incorporate data around social determinants of health and make it accessible to members. It will not be uncommon for members to request corrections to the data, which presents an interesting challenge for health plans because they must verify that members’ assertions are correct. Health plans should think about how they will respond to members’ inquiries; for example, will fielding questions require additional customer service staff?. They also will need to invest in software or support for verifying member identity and strengthening data integrity, especially as data becomes available for consumer viewing in near-real time.

Digital tools will become health plans’ new currency

When consumers have choices regarding which plan to enroll in, the quality of the digital health experience a plan offers will become a competitive differentiator. “It’s going to come down to the tools that they offer, from a digital health perspective: Do they make telehealth visits easy to schedule and complete? Do they make it easy for members to access care, clinical results, and claims data so they can manage their care and care expenses?” says Genevieve Morris, senior director of clinical interoperability strategy at Change Healthcare. “I think payers are being really forward-looking with this. They’re seeing this as an opportunity to offer digital health tools to their members that they previously couldn’t offer as a service.”

It’s important to note that health plans will encounter new issues around compliance as the Cures Act is implemented. One concern relates to parental access to their children’s health data, given that state laws around parents’ access to sensitive health information vary. There will be questions and challenges related to data privacy that payers have not yet experienced but must be prepared to address as members gain enhanced access to their data

Also of concern: The extent to which the government will help managed Medicaid plans comply with the Cures Act, given the expense in implementing and administering technologies that expand data access.

Payers will need to consider the value of aligning with third-party digital app developers

Once data standards are in place for sharing data among payers, providers, members, and the third-party apps that consumers choose, such as wellness apps and apps for chronic care management, the door will open for greater collaboration between health plans and digital app developers. For example, there is strong potential for health plans to draw upon the expertise of digital health app specialists to more effectively engage at-risk populations in managing chronic disease. “That’s a benefit to the consumer and the payer,” says Schwaninger at L.A. Care Health Plan. “Some payers may be willing to pay a small fee to third-party app developers for reducing costs of care and improving members’ health outcomes.”

Experts expect the range of digital health apps to grow exponentially as the Cures Act takes effect. “I think it will be the Wild Wild West for digital health app development: We don’t yet know what’s going to pop up, but we know that app offerings will grow,” says Hong Truong, M.P.H., senior program investment officer at the California Health Care Foundation’s Innovation Fund. Another benefit to data standards under the Cures Act: improved capabilities for collecting data related to quality metrics and prior authorization requests, which could significantly enhance efficiency.

These are interesting issues to consider, and they could have a deep impact on health plans as Cures Act implementation gets underway. By taking the time to think about these issues now, health plan leaders can better position their organizations for success under the Cures Act. The impact: enhanced data integrity, a better member experience and a stronger competitive position.

Jason Bihun is chief commercial officer for Verato, a Washington, D.C.-based company that specializes in next-generation patient matching solutions for healthcare

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