CMS official notes proposed interoperability rule will impact health plans, too

The federal government expects to use its leadership, clout and some emerging federal regulations to push health payers to share more data.

Those regulations, now open for comment, lay out crucial first steps that will engage health plans in nationwide interoperability efforts, said Alexandra Mugge, deputy chief health informatics officer for the Centers for Medicare and Medicaid Services at the AHIMA19 Health Data and Informatics Conference in Chicago.

Speaking at the annual conference of the American Health Information Management Association, Mugge says CMS’ Interoperability and Patient Access Proposed Rule is a first step in an effort to improve data sharing among all healthcare entities while increasing the pressure against those that block information exchange.


“This rule is a first of its kind,” she said. “We usually write our rules for a particular audience, but this rule impacts almost everyone that we regulate.”

While much attention has been paid to interoperability requirements for healthcare providers, the rule contains five proposals that will affect payers, Mugge noted.

The proposed rule requires payers to build patient access application programming interfaces (APIs), which would be expected to function similar to the government’s Blue Button initiative, which makes federal program claims data easily accessible to consumers covered by those programs.

The rule also would require payers to make provider directories available through an API. This is emerging as a serious issue that is a bottleneck within the healthcare industry, with inaccurate or outdated information adding to systemic inefficiency and potential unnecessary cost for consumers. ‘We have a lot of comments coming back on this, reporting 70 percent or lower accuracy rates.”

The rule would require payers to freely send patient data to each other, as consumers switch plans over the course of their lifetimes. This would enable each insurer to have a seamless record of a patient’s health claims history. “I want that data to follow me through my healthcare journey,” Mugge said. “So when you enter Medicare, you would have access to (all your previous health claim history).”

The rule also proposes the creation of a trust network to enable ease of data sharing through a variety of healthcare organizations.

Finally, the rule would require improved data sharing for dual eligible beneficiaries covered by both Medicare and Medicaid programs, requiring states to send relevant data on those they cover through Medicaid to Medicare on a daily basis.

Mugge said the improvements in information flow will only benefit health plans. “It will help them improve their relationships with their patients,” she explained.

CMS also is leading through example, and by enacting policies that could shift market expectations because of its large market presence—federal programs now cover at least 85 million beneficiaries, and another 40 million patients are covered by Medicare fee-for-service plans, she said.

The BlueButton 2.0 initiative enables users to employ an app that gives them access to all their federal program claims data, displaying it “in a way that makes sense for consumers,” she said. “This could be huge for patients who are managing multiple conditions.”