Maximize ROI on your payer-to-payer API compliance journey
By: Prabal Basu and Shreesh Tiwari
The Centers for Medicare & Medicaid Services (CMS), in December 2022, proposed new changes to the payer-to-payer application programming interface (API) (P2P API) that will go into effect in January 2026. With these new and expanded CMS requirements, payers have just six to eight quarters to navigate and interpret the new regulations, ensure they are compliant and establish a sustainable interoperability model. By beginning their P2P API journey now, payers can get an immediate return on investment (ROI) on their cloud assets if they take a strategic approach. Instead of just focusing on the CMS mandate as a compliance requirement, payers should leverage the requirements of the P2P API to establish a clinical data exchange (CDE) that can drive business value with their existing cloud investments, which may be sitting idle. A CDE has the potential to be game changer for health plans because it fulfills two goals in a single effort:
1. It allows health plans to exchange clinical data on its members with payers and providers, thereby accelerating value-based care (VBC).
2. It fulfills the CMS mandate with minimal incremental effort.
Another benefit of implementing a CDE, is that it enables payers to exchange clinical data securely with other payers and providers in accordance with the Fast Healthcare Interoperability Resources (FHIR) standard. For a payer, this influx of new structured and semi-structured clinical data on its members can be easily analyzed and assimilated with existing members and claims data. By applying the right cloud and data engineering capabilities this will yield significant business benefits, such as accelerated health risk assessments and risk stratification.
Factors that accelerate ROI on interoperability
Currently, three market trends are advancing a payer’s ability to accelerate ROI on interoperability investments:
1. Widespread FHIR adoption: More than 84% of hospitals and 61% of clinicians adopted and implemented certified API technology enabled with FHIR.
2. Adoption of FHIR engines powered by cloud hyperscalers: Azure, Amazon Web Services (AWS) and Google Cloud Platform cloud-managed services are removing the need for higher fixed cost outlays, meaning payers can adopt a pay-as-you-go cloud pricing model. In our experience, payers can configure FHIR infrastructures of cloud hyperscalers to support both CMS and non-CMS use cases, thereby accelerating ROI.
3. Easy querying of FHIR data: Cloud-managed services, such as Azure Synapse analytics, allow querying of FHIR data with minimal effort, accelerating insights from the inbound member clinical data in the FHIR format.
Two use cases and benefits of a payer CDE
Risk stratification and longitudinal patient record (LPR) are the two main use cases from a VBC lens. The table below outlines how they can improve the quality and efficiency of care delivery:
Next steps for payers to realize ROI with interoperability
We recommend that payers consider the following strategies to implement interoperability capabilities like CDE and CMS’s P2P API:
1. Establish an interoperability managed services model: A managed services model continuously delivers core capabilities and regulatory compliance as a service. The model is comprised of a multi-disciplinary team, which could include payer mandates, payer operations, cloud engineers, data analysts and business readiness, that delivers incremental capabilities across non-CMS and CMS use cases.
2. Leverage your investment in the cloud: Cloud platforms such as Microsoft’s Azure API for healthcare, AWS HealthLake and Google’s Healthcare API support multiple use cases securely at scale and at a significantly lower cost than vendor solutions.
3. Pursue new insights: Structured query language on FHIR allows querying of FHIR data received from other payers, enabling analytical use cases such as:
LPR: By ensuring that the data exchanged is cumulative, meaning each payer adds new data to the existing data set rather than replacing or deleting previous data, the member can have a complete picture of health history across different payers.
Risk stratification: By leveraging the clinical data exchanged in the P2P API, payers can access the United States Core Data for Interoperability v1 data set, which is a standardized set of health data classes and data elements that are essential for nationwide interoperability. This can help them to better assess their members’ risk levels and tailor their care plans accordingly.
By following these strategies payers can get more ROI with CMS-mandated P2P API and can leverage the requirements of the P2P API to establish a secure CDE. Deploying these strategies, payers can comply with the CMS mandate and gain a competitive edge in the VBC market.
