One of the greatest challenges in healthcare is keeping up with the changing landscape. Considering only since the beginning of 2019, the Centers for Medicare and Medicaid Services (CMS) and other federal agencies, such as the Office of National Coordinator of Health IT (ONC) and the Department of Health and Human Services (HHS), have introduced a number of rules as a measure of upholding their goal of empowering patients and enhancing healthcare efficiency. We’re at a very critical juncture in healthcare and from a regulatory perspective, there are a few key rules that merit a special focus which will have a great impact from both a clinical and financial standpoint.
The MyHealthEData Initiative in 2019
The MyHealthEData initiative, launched in March 2018, aims to “empower patients by ensuring that they control their healthcare data and can decide how their data is going to be used, all while keeping that information safe and secure.” Only a few days back, CMS upped the ante for better data access by expanding this initiative and announcing the pilot of “Data at the Point of Care.”
The Data at the Point of Care (DPC) pilot will be connecting providers with Blue Button data, where providers can access claims data to learn more about their patients and their previous diagnoses, procedures, and prescriptions. While providers had to comb through several hundred data sets previously, the DPC program would aim to make access to data easier and right within their workflows.
This announcement follows the relaunch of the Blue Button initiative, or Blue Button 2.0, that grants access to health data and enables patients to send that information using FHIR-based healthcare apps.
In a nutshell, these moves come as an overall push from CMS to promote better access to data and 100% healthcare interoperability. In addition to enabling data access, CMS has also been targeting information blocking, as reflected by 2019 MyHealthEData updates. With these measures, both patients and providers will have the required insights to make more informed healthcare decisions.
The Trusted Exchange Framework and Common Agreement
In April 2019, ONC published its second draft of the Trusted Exchange Framework and Common Agreement (TEFCA), focusing on three high-level goals:
• Providing a single ‘on-ramp’ to nationwide connectivity
• Enabling Electronic Health Information (EHI) to securely follow the patient wherever needed
• Supporting nationwide scalability
TEFCA is basically a common set of principles which serve as “rules of the road” for nationwide electronic health information exchange across disparate health information networks (HINs). The framework, which was mandated by the 21st Century Cures Act, provides a set of policies and procedures along with technical standards required to enable healthcare data exchange among providers, state and regional HINs, and federal agencies.
The first draft was released in January 2018, and one among the key changes in the second draft is that qualified HINs (QHINs) would have 18 months to implement this framework rather than just 12 months. Additionally, TEFCA is also an attempt to resolve some long-standing issues around interoperability, such as costly point-to-point interactions and lack of connection, between national networks and local HINs.
These changes will not only strengthen the flow of information, but will also develop the ability for timely bi-directional exchange, which will be essential in responding to health threats and epidemics, and in order to inch closer to the goals of nationwide interoperability.
Another initiative that took healthcare by storm was the launch of direct contracting payment models for primary care.
In April 2019, HHS announced that CMS will launch the Primary Cares Initiative in 2020, which would make one in four primary care providers eligible to engage in direct contracting models. The initiative is supposed to have two tracks- Primary Care First and Direct Contracting- along with five different value-based reimbursement models with different levels of financial risks. The former is designed for small primary care practices in mind, and the latter, for larger primary care practices.
Through the Primary Care First (PCF) model, PCPs will aim to reduce total Medicare spending, enhance the quality of care, and advance patient outcomes. Additionally, if the participating providers failed to perform on the measures and couldn’t decrease utilization or the spike in the cost of care, they would have to bear some financial responsibility.
On the other hand, the direct contracting track will offer organizations two options- global and professional- and a potential opportunity for geographic contracting. The participants will receive a fixed monthly payment, ranging from a portion of the expected cost of care to the total cost of care.
This comes as a very significant move from CMS, which is trying to ensure that providers have as many options as possible to reach their value-based care goals. In the words of Seema Verma, CMS Administrator, “Our Primary Cares Initiative is designed to give clinicians different options that advance our goal to deliver better care at a lower cost while allowing clinicians to focus on what they do best: treating patients.”
The road ahead
Back in the day, when automobiles were invented and the world was introduced to this new technology, the world was impressed. People consider the birth of the automobile industry to have occurred in 1886, and since then, we have been witnessing great inventions; yet, we still struggle with vehicle blind spots while driving. Although healthcare is nothing like automobiles, we have some blind spots in which we struggle. However, looking at the federal regulations, I’d say we are on the right track!
Abhinav Shashank is CEO of Innovaccer, a Silicon -Valley based healthcare data analytics company.