Interoperability promises a superhighway of data, but some hospitals are stuck in the parking lot

Health Care Current | March 19, 2019

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies, and provides updates and insights on policy, regulatory, and legislative changes.

My Take

Interoperability promises a superhighway of data, but some hospitals are stuck in the parking lot

By Steve Burrill, vice chairman, US health care leader, Deloitte LLP

Regardless of where I am, interoperable banking systems give me the ability to access accounts, deposit checks, transfer money, and pay bills—all with a few taps on my smartphone. Unlike my financial transactions, which are online and accessible, bits and pieces of my health history are scattered throughout the country. A lifetime of medical test results, drug prescriptions, specialist visits, and diagnoses are sitting in paper files and computer systems owned by physician offices, hospitals, and vendors in more than a dozen cities in which I’ve lived and worked. Similarly, my claims history is owned by a handful of health plans that have covered me during my career. None of these stakeholders can share any of this information with each other or with me.

Interoperability in health care appears to be several clicks behind financial services, and hospital executives regularly tell me they are worried about the impact this could have on quality and outcomes. Imagine if our complete health history existed in one place and could be accessed as easily as we pull up a checking-account balance on a computer or phone. Radically interoperable data promises to let consumers own their personal health information and share it with stakeholders (in real time) through a secure multi-lane superhighway of data.

Data belongs to patients, says CMS chief

At last month’s HIMSS conference in Orlando, US Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma outlined interoperability rules that were recently proposed by the US Department of Health and Human Services (HHS). If finalized as proposed, provisions of these rules would take effect as soon as January 1, 2020, leaving limited time for health care stakeholders to prepare.

Historically, when we have talked about interoperability, it has been among health systems and physicians. Patients, their families, and care teams have generally not been part of the discussion. Verma emphasized that patient data belongs to patients, and health plans, health systems, physicians, and government entities need to make it possible for patients to access and share this information. The idea that patient data belongs to providers or vendors, she told attendees, is “an epic misunderstanding.”

Taking baby steps toward interoperability is no longer an option

Many hospitals are unable to share information across their own software platforms, let alone with other patients, health systems, health plans, or physicians outside their network. Some hospitals and health systems are investing in software add-ons and patches to integrate their various software systems. Others have figured out how to share data with physicians who aren’t on the same software platform, but who are part of their Medicare Shared Savings Program (MSSP). However, there is typically a lag when sharing this information and developing dashboards—rather than the near-real-time data sharing that interoperability could deliver.

While hospital leaders have been taking baby steps to improve interoperability, they should pick up the pace to get to the future of health that CMS envisions. As health systems and physicians enter into more risk-based contracts, they need to be able to seamlessly share data to reduce costs and improve outcomes. All stakeholders—the patient, the clinician, the hospital, the drug and device manufacturer, and the health plan—should be committed to interoperability. Hospital and health system leaders should consider these strategies to improve interoperability:

  • Resolve internal data issues: Disparate IT systems (e.g., EHRs, claims, supply chain, staffing, imaging software systems) are prevalent in some hospitals, which can make it difficult to perform in-house analytics, let alone share data with other facilities. Moreover, technical challenges can keep hospital leaders from using data for clinical or business decisions. Health system leaders should identify the data elements that need to be shared with patients and third parties and work with their vendors to standardize how this information is captured across systems. HHS’s recently proposed rule could push providers to accelerate their transition to interoperability. The proposed rule would require the health sector to adopt standardized application programming interfaces (APIs), which could eventually make it possible for individuals to access health information through smartphones and other mobile devices—and potentially make it easier for disparate systems to interact.
  • Work with vendors and physicians to improve EHR usability and interoperability: EHRs are digital representations of paper charts that are used primarily for billing purposes. The proposed guidance seeks to improve the way EHRs connect, which could make them more useful to physicians. Many physicians are frustrated by the lack of interoperability with EHRs and the burden of documentation, according to Deloitte’s recent survey of 624 physicians. More than 60 percent of surveyed physicians say interoperability needs improvement. We also found that vendors and health systems don’t always seek feedback from the physicians who are using the technology. Including physicians in efforts to improve EHRs could result in a win-win-win for health systems, doctors, and consumers.
  • Relinquish control of data: Before consumers take more ownership of their data, health care stakeholders should give up control. In announcing the proposed rule, CMS said “information blocking” undermines efforts to improve interoperability. The proposal calls for hospitals and other providers to be reported if they limit the availability, disclosure, and use of electronic health information. “Making this information publicly available may incentivize providers and clinicians to refrain from such practices,” CMS said in a statement.
  • Build trust: For health plans, giving consumers access to their claims data could help providers make more informed care decisions, improve safety, and reduce redundancies. But health care stakeholders should trust each other. Health systems and health plans tend to have different goals and historically have not trusted each other. Add life sciences companies into the mix and we have a stalemate in the battle for health information. Moreover, efforts to build a world of interoperability will likely come to a screeching halt if the data infrastructure isn’t fully secure or if patients don’t trust it. Data security and privacy should be at the center of the evolution toward interoperability.

While banking is far ahead of health care in terms of interoperability, medical information is far more complex than financial information. It comes in a variety of formats and typically includes highly nuanced and personal data. However, once interoperability issues are resolved between departments within a hospital and among hospitals in a health system, radical interoperability should be an easier transition. This is becoming increasingly important given the amount of health data being generated through wearable devices, apps, and connected at-home medical devices. As more care is delivered at home—rather than at a doctor’s office or hospital—interoperability will likely become indispensable.

For more on how radically interoperable data is transforming the life sciences and health care industry, view our recent webcast. And, for more on our broader vision for the future, visit our resource hub where you’ll find articles, videos, podcasts, and more.

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In the News

Proposed 2020 White House budget seeks to reduce health care spending

The White House released its fiscal year (FY) 2020 proposed budget on March 11. The budget request is an annual activity where the administration lays out its policy priorities affecting spending across the entire federal budget. Many of the ideas in the most recent budget proposal would require administrative or statutory action to implement and would be shaped by stakeholder input.

The budget request contains a $2.7 trillion spending cut overall. It would reduce funding to HHS by 12 percent—to $87.1 billion—in 2020. The budget also would cut Medicaid spending by nearly $1.5 trillion—from 2020 through 2029—by repealing the Affordable Care Act’s (ACA’s) Medicaid expansion and converting the program’s funding to block grants or per-capita spending caps (a policy that would require statutory change to implement). The White House also seeks to reduce Medicare spending by $845 billion during the next ten years by changing payments for physicians and hospitals, in addition to renewing efforts targeting fraud and abuse.

The proposed budget includes the following other provisions, which would affect several agencies:

  • Mandating work requirements among various safety-net programs, including food stamps, federal housing programs, and Medicaid. The administration invited state Medicaid programs to apply for 1115 waivers to add work requirements to their programs. To date, CMS has approved eight such waivers (see the March 12, 2019 My Take).
  • Increasing funding to the US Department of Veterans Affairs by 7.5 percent—a $6.8 billion increase from last year. This increase would be used to implement provisions to the MISSION act, which Congress passed in 2018 to consolidate community care programs and help veterans access private physicians (see the November 8, 2018 My Take). The proposed budget would also increase funding to modernize the VA’s EHRs, improve mental-health services for veterans, and boost medical services specifically tailored to female veterans.
  • Allowing states to amend their Medicaid plans, without seeking waivers, to charge higher copayments for non-emergency use of hospital emergency departments (EDs).
  • Allowing CMS to issue guidance so supplemental payments made to hospitals by state Medicaid programs are “supported by robust and timely data.” The provision also would extend reductions in Medicaid’s disproportionate-share hospital (DSH) payments (see MACPAC news item below).
  • Improving program integrity for the 340B drug-discount program, including setting broad standards for program participation and requiring that all participants report their use of program savings.

In addition to the proposed cuts, the 2020 budget echoes last month’s State of the Union address by calling for an initial installment of $291 million targeted to communities where HIV is spreading (see the February 12, 2019 Health Care Current). However, the budget seeks to reduce US funding for global AIDS programs and would cut expenditures for the Centers for Disease Control and Prevention (CDC) by 10 percent. While the budget seeks to boost funding for pediatric cancer research by $50 million, it also calls for cutting the National Institutes of Health (NIH) budget by $4.5 billion, or about 13 percent.

(Source: The Washington Post, What Trump proposed in his 2020 budget, March 12, 2019).

MACPAC discusses whether Medicaid should be included in administration’s proposed drug-rebate ban

During its March meeting, members of the Medicaid and CHIP Payment Access Commission (MACPAC) advisory panel discussed HHS’s recent proposal to ban rebates from Medicare Part D. The proposed rule seeks to reduce out-of-pocket costs for Medicare beneficiaries by eliminating the rebates drug manufacturers give to help offset list prices. This change in policy could provide manufacturers with a financial incentive to reduce list prices for their products and replace rebates with point-of-sale discounts.

According to the commissioners, though the proposed rule addresses Medicare Part D, Medicaid could see a downstream effect if the rule is finalized. MACPAC’s advisory panel discussed whether HHS should specifically protect the rebates that drug manufacturers give to Medicaid plans under safe-harbor laws. After discussing whether HHS could exclude Medicaid from the proposed rule, MACPAC’s commissioners decided they will submit a formal letter asking HHS to protect Medicaid’s supplemental rebates.

MACPAC commissioners addressed other policy topics as well. One issue they took up is whether Congress should place stricter limitations on Medicaid disproportionate-share hospital (DSH) payments. MACPAC’s advisers considered three options for changing DSH calculations:

  • Including all payments and costs in the Medicaid-shortfall calculation, which would write CMS’s prior policy into statute.
  • Excluding payments or costs for Medicaid patients who have third-party coverage.
  • Combining the above two options and establishing different rules for various third-party coverage situations.

MedPAC commissioners discuss payments for post-acute care

The Medicare Payment Advisory Committee (MedPAC) met on March 7 and 8 to discuss Medicare payment policies, including strategies for improving the accuracy of Medicare fee-for-service payments for post-acute care. MedPAC commissioners agreed that a future payment system for post-acute care facilities should be based the patient’s stay, rather than on the entire episode of care. An episode-based payment system might encourage post-acute care facilities to discharge patients too quickly, according to MedPAC’s analysis, because they would receive less money for longer episodes of care. However, MedPAC’s commissioners indicated they would be open to exploring episode-based payments in the future.

Medicare fee-for-service has separate payment systems for each post-acute care setting—home health, skilled nursing facility (SNF), inpatient rehabilitation facility, and long-term care hospital. A key concern for tying payments to the entire episode of care was lowering the amount of patient transitions—or handoffs—made during post-acute care. One commissioner suggested that CMS could create episode-based Medicare payment bundles that could generate savings in post-acute care spending.

CMS seeks input on interstate sale of health insurance coverage

CMS is seeking input on how to make it easier for health plans to sell coverage across state lines through a request for information (RFI) posted March 6. CMS is asking for recommendations on how to expand access to coverage and simplify interstate sales under Section 1333 of the ACA. The provision allows health plans that are based in different states to enter a Health Care Choice Compact. Under the Compact, health insurers could sell individual qualified health plans (QHPs) in any state that participates in the agreement. States that want to participate in a Compact would first need to enact legislation authorizing the move. So far, no states have passed legislation, nor entered a Compact. According to CMS Administrator Seema Verma, the agency will use any information submitted to “create a more dynamic health insurance market with more insurers participating and competing to meet the needs of the American people.” The RFI is available for public comment for 60 days following the posting.

(Source: CMS, CMS seeks recommendations that allow Americans to purchase health insurance across state lines, March 6, 2019)

House Committee on Energy & Commerce holds hearing on generic drugs

On March 13, the House Committee on Energy & Commerce Subcommittee on Health held its first hearing on drug pricing. This followed hearings on the same topic held by other House and Senate committees (see the March 12, 2019 Health Care Current). During the hearing, committee members discussed several proposed bills that would address barriers that can keep generic and lower-cost drugs from entering the market. Some of the bills discussed are:

  • H.R. 938, the "Bringing Low-cost Options and Competition while Keeping Incentives for New Generics (BLOCKING) Act of 2019." The legislation, which was introduced by Reps. Kurt Schrader (D-Ore.) and Earl “Buddy” Carter (R-Ga.), discourages generic first filers from “parking” applications and delaying the start of their 180-day generic exclusivity.
  • H.R. 965, the "Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act of 2019," introduced by Reps. David Cicilline (D-R.I.), F. James “Jim” Sensenbrenner (R-Wis.), Jerrold “Jerry” Nadler (D-N.Y.), Doug Collins (R-Ga.), Peter Welch (D-Vt.), and David McKinley (R-W.Va.). This would establish a process for generic manufacturers to request authorization to obtain sufficient samples for testing. The Senate Finance Committee discussed CREATES in a February hearing (see the March 5, 2019 Health Care Current).
  • In addition to CREATES, H.R. 985, the "Fair Access for Safe and Timely (FAST) Generics Act of 2019," introduced by Reps. Welch, McKinley, and Cicilline, seeks to establish an authorization process that would make it easier for generic-drug manufacturers to access samples of approved prescription drugs, which are needed to develop generic versions of these drugs.
  • H.R. 1499, the "Protecting Consumer Access to Generic Drugs Act of 2019," introduced by Rep. Bobby Rush (D-Ill.), would prevent brand-name drug makers from paying generic drug manufacturers to keep generic equivalents out of the market.

Breaking Boundaries

Innovative digital health solutions aim to make health care more accessible, data more actionable

The fourth annual Boston Scientific Connected Patient Challenge, which was held March 13, featured six startup finalists that are working to reduce some of the burdens associated with chronic disease. Each company gave its pitch to a panel of judges, and the winner received $30,000 of in-kind support.

Nutrimedy took the top prize for a HIPAA-compliant mobile and web service that uses an algorithm to match chronically ill patients to registered dieticians who can offer guidance specific to the patient’s illness. Patients have access to photo meal logs, blogs, and recipes, and are able to connect to counselors via video or instant messaging. The Massachusetts-based company also works with employers to offer wellness solutions to their workers.

BreathResearch, a California-based company, took second place for its spirometer and lung sound analysis device that connects to a patient app and clinician-facing support platform.

Other contest participants included:

  • Control:Diabetes, which has app that can predict high- or low-blood-sugar events.
  • EinsWorld, which featured a machine-learning algorithm that can predict adverse cardiac events.
  • RTM Vital Signs, which showcased an implantable vital-sign monitor.
  • SpeechMed, which uses a take-home tablet and app to translate care instructions into the patient’s (or their caregiver’s) native languages.

All of the products and services offered by the contestants aim at making health care more accessible to patients and making the data more actionable.

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