While telemedicine and digital health records have helped revolutionize health equity, person-centered care, and access, it is regulations in the healthcare space that are pushing forward the next generation of technology across the industry. Earlier this year, CMS made its annual rate announcement for Medicare Advantage and Part D, which advances the agency’s vision to lead progress related to social determinants of health (SDoH). More and more, barriers related to income, education, and ability are being realized as major factors in patient access, outcomes, and member management but can remain out of reach without the proper IT infrastructure.

As mandates are continually being introduced and the need for increased interoperability is growing, healthcare systems need to enable a modular, adaptable IT infrastructure approach. Without new IT systems in place, health plans are missing out on crucial data that can foster a more personal, effective, and affordable health care ecosystem. Mandates impact how health plans’ tech adoption moves forward, including the implementation of SaaS and cloud-based infrastructures to more quickly meet regulatory deadlines. These advancements will help ensure health plans not only stay current but meet member expectations and help push health equity further to center stage.

Fortunately, the growing use of SaaS/Cloud enabled technology, AI, and APIs – to name a few, is designed to adapt in real-time and grow with changing legislation and mandates, including this year’s rate announcement and other recent calls to push forward healthcare interoperability and patient data sharing.

The primary intent of the CMS 2024 Medicare Advantage and Part D Rate Announcement is to “advance health equity; drive comprehensive, person-centered care; and promote affordability and the sustainability of the Medicare program.” This requires health plans to create new configurations for IT systems and reassess interventions like In-Home-Assessments (IHAs).

According to analysts, health plans may experience a 3-5% reduction on payments, and providers may experience more penalties for inaccurate or incomplete coding, swaying incremental value for health plans. Health plans will need to assess existing tech infrastructure to ensure the most accurate and streamlined risk scoring and coding to optimize care, understand risk, and secure accurate payments.

The Interoperability and Patient Access mandate of 2020 was a massive step in the right direction for the industry. This is due to its enforcement of improved patient access to healthcare data enabling better care coordination, experience, and outcomes.

The ruling also enables subsequent rulings leveraging the required FHIR® APIs to improve other processes in healthcare. Once health plans put an interoperable infrastructure in place, they’d be able to leverage that investment to improve the prior authorization process. The structure and standards of Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) will help ensure prior authorizations don’t postpone timely care or result in costly, time-consuming processes.

With better EHR integration and data retrieval processes, payers and providers will see increased efficiencies, reduced friction, and greater cost savings. Not to mention, better healthcare outcomes for patients. It has the capability to soften pain points across the industry, like poor member experience, suboptimal patient outcomes, and provider burnout and abrasion.

Easy adoption of new technology isn’t ubiquitous. Larger health plans are better positioned to more efficiently adopt new technology and processes to meet shifting regulations by nature of their size and resources. Smaller health plans, and many community-based health plans, may have a tougher time adopting new technology as resources are leaner.

Scalable, standardized, and cloud-based solutions that foster increased data sharing between payers, providers, and patients to effectively fulfill the goals of the quadruple aim, are capable of overcoming inefficiencies and friction and enabling ongoing compliance for plans of all sizes. Such solutions can create a buildable infrastructure for sustained business value through administrative optimization, increased member satisfaction, and better collaboration across payers and providers.

Long-term value of mandates on healthcare technology

The good news is, these mandate-driven technology investments power long-term value and benefits to the organization. Through the adoption of enhanced technology solutions, health plans can reconfigure how they use their data to increase health equity. Interoperable data and infrastructures are helping speed up and automate cumbersome shared workflows, like prior authorization, that can result in improved member experience, outcomes, and better payer and provider collaboration. And finally, giving patients access to their healthcare data creates a more informed and empowered healthcare consumer and it can have a long-term effect on care quality and costs.

Essentially, mandates have ushered in an era of healthcare technology infrastructure that builds on itself (for example, the CMS-0057-P proposed rule requires the use of FHIR APIs and builds upon previous regulations). By having an agile, secure, and scalable infrastructure in place, such as cloud, SaaS technology, and artificial intelligence to help speed up and automate processes, healthcare industry stakeholders can anticipate and respond to mandates more quickly while also building business value.

Bottom line, it’s incredibly important that healthcare organizations think of their mandate-driven investments as a way to build long-term value for their business rather than just a box to check, as regulations will continue to compound and build on each other.

By Elaina McMillan, Director of Product Marketing, Edifecs

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