To Share Data With Medicare Advantage, Medicare Must Go Further On Interoperability


Interoperability—which the federal government has defined as “the flexibility of two or more systems to exchange and use the data once it’s received”—is critical to creating our health care system more efficient and seamless for patients and consumers.

Imagine a system where prior authorization is handled between payers and providers at once for the patient or where a consumer can get details about the fee of a procedure or a prescription and where to get it by tapping a smartphone. Similar transactions happen daily in lots of other sectors, but for years we’ve got struggled to consistently enable this information portability in health care.

While Medicare has spurred the evolution of information exchange, Medicare fee-for-service is currently not included within the critical area of payer-to-payer data exchange. In a patient-focused, interoperable world, it doesn’t make sense for a national payer covering some 38 million Americans to be outside these exchanges. With Medicare Advantage (MA) plans covering an increasing share of Medicare beneficiaries—half of Medicare beneficiaries are projected to be in MA plans perhaps as soon as 2023—traditional Medicare urgently needs to construct a greater way of exchanging data with MA plans. As tens of millions of beneficiaries see more selections than ever of their Medicare option ensuring continuity of care would require portable clinical data.

Why Is It Necessary To Connect Medicare Fee-For-Service Into Ongoing Interoperability Efforts

Due to the bipartisan twenty first Century Cures Act, signed into law in December 2016 by President Barack Obama, interoperability took a significant step forward. In implementing the laws, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) built a recent foundation for information exchange using HL7® FHIR® Application Programming Interfaces (APIs). Former CMS Administrator Seema Verma noted that recent rules would break down “digital silos” by requiring “payers to step as much as the plate and share that wealth of claims data directly with patients through a secure, standards-based API.”

Verma set the stage for a second phase of interoperability to share “patient claims, encounter data and clinical data on to providers’ EHRs,” to digitize prior authorization, and to require certain payers to make use of a FHIR API when customers change plans. Current CMS Administrator Chiquita Brooks-La-Sure has pledged to meet the “goal of enabling patients’ health data to follow them in the event that they switch medical insurance plans.”

We agree with this approach: policy makers must embrace interoperability as a technique to improve customers’ experience, not as one other government mandate or “checking a box.”

Just as payer-to-payer data exchange will soon be required to support patients who switch plans in other markets, we should always expect the identical between Medicare fee-for-service and MA. Medicare beneficiaries have the choice to change between Medicare fee-for-service and MA inside certain enrollment periods, just as tens of millions of Americans may switch plans during their employer’s open enrollment period. As Health Affairs articles (in 2015 and 2021) and other surveys have found, plan switching occurs between fee-for-service and MA to various degrees, and empowering MA plans with claims data to see a beneficiary’s history will only improve care.

For instance, Cambia—where two of us (Dodge and Anderson) work and which administers MA plans within the Pacific Northwest—saw about 5,500 recent members join its MA plans from Medicare fee-for-service in 2022 but didn’t receive their claims history, information that would help ensure a seamless continuity of care.

Interoperability is vital to securely and quickly unlocking patient and consumer data across the health care system, harnessing it for higher clinical decision making. From each individual plans’ perspective and for the industry as a complete, interoperability will improve our Medicare beneficiaries’ experience by making care as seamless as possible. As an illustration, if our MA plans had claims history for the beneficiaries who switched from fee-for-service, they may streamline prior authorization approvals and prioritize members for medication reviews.

CMS Has Led The Way For Interoperability; It Can Do Even More

The federal government has developed several APIs to spur exchange with the private sector. Chief amongst those initiatives is Blue Button, which began with the Department of Veterans Affairs in 2010 and later expanded to CMS and the Defense Department. In 2018, CMS took Blue Button a step further—a Blue Button 2.0 of sorts—by creating MyHealtheData to speed up the event of tools for health data exchange and consumer empowerment.

But Blue Button has its limitations for payer-to-payer exchanges. Blue Button is barely available to the Medicare beneficiary, who must press the virtual button to drag down their data and either share it directly or authorize an approved app to share it. In line with statistics last updated at the top of 2021, a little bit greater than one million beneficiaries—a fraction of those covered by Medicare—have done so.

To speed up interoperable data exchange, CMS should recognize its vital role as the biggest payer within the country and share Medicare fee-for-service data that might assist MA plans in providing look after beneficiaries. Such APIs exist already: the Beneficiary Claims Data API for accountable care organizations, the Data at Point of Care API pilot, and—perhaps most relevant—the AB2D API that permits stand-alone prescription drug plans to receive fee-for-service Medicare data. AB2D allows prescription drug plans (but not MA plans with prescription drug coverage) to access Medicare claims data for higher medication management. A recent API would in essence be an “AB2C” interface—in other words, sharing fee-for-service’s Parts A and B to Part C—for MA plans so that they could higher understand a beneficiary’s claims history before a switch from fee-for-service. While AB2D was required as a part of the Senate Finance Committee’s CHRONIC Care Act, after which included within the 2018 Bipartisan Budget Act, it mustn’t require an act of Congress to determine a recent API. In any case, outside of AB2D, CMS has put out the overwhelming majority of its API developer tools under existing authority.

Interoperability 2.0—Necessary Marker For A Latest Medicare AB2C API

While the increasing popularity of MA must be enough justification for a recent API, the necessity for AB2C shall be much more stark once payer-to-payer data exchange becomes a reality in other settings. In the primary interoperability rule, finalized in 2020, CMS sought to require payers to exchange data with other payers at a patient’s request. Nevertheless, CMS is now exercising enforcement discretion on that requirement, pending additional rulemaking. Administrator Brooks-LaSure explained that this decision was based on the “operational challenges and risks to data quality within the absence of specific data exchange requirements and standards, particularly the dearth of a requirement for a standards-based API.”

On the tail end of the last administration, CMS published what was sometimes called an “Interoperability 2.0” regulation, which might have added “several recent provisions to extend data sharing and reduce overall payer, health care provider, and patient burden through the proposed improvements to prior authorization practices.” But critics felt that this regulation was pushed through the method without sufficient comment. Moreover, it only applied to qualified health plans in federally facilitated exchanges and Medicaid and CHIP managed care organizations. It didn’t apply to MA plans in order that it could avoid being a significant rule under the Congressional Review Act, to avoid a 60-day comment period.

The Biden administration withdrew the ultimate rule but is just not retreating from interoperability. In a 2021 blog post, Brooks-LaSure described progress made up to now, even through the pandemic, and highlighted efforts “to develop and finalize recent rulemaking regarding payer-to-payer information exchange.” This past March, the administrator gave an update to industry stakeholders that a recent interoperability regulation can be coming “soon.”

If CMS does expand a proposed “Interoperability 2.0” rule to incorporate MA plans, why not also announce the event of an AB2C API, to point out the federal government’s commitment and stake in data exchange? One option can be to no less than pilot such an API in a regulatory sandbox much like CMS’s Data on the Point of Care API. Higher yet, why not align access to a recent AB2C API with the ONC’s emerging FHIR-enabled Trusted Exchange Framework and Common Agreement (TEFCA)? Making TEFCA the trail for MA plans to access Medicare fee-for-service data can be an enormous accelerator to TEFCA adoption overall.

The federal government continues to play a critical leadership role within the interoperability movement in health care. Constructing upon that leadership by releasing an AB2C API wouldn’t only give beneficiaries a neater technique to share their Medicare fee-for-service history, it will also further speed up the US toward the long-held dream of interoperable health data.

Authors’ Note

Kirk Anderson and David Dodge are employees of Cambia Health Solutions, which operates regional health plans—including Medicare Advantage plans—that serve greater than 3.2 million members in Oregon, Washington, Idaho, and Utah.


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