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Posted by on Sep 1, 2015 in Uncategorized | 0 comments

The New Frontier: The Era of Healthcare Provider Data Transparency

The New Frontier: The Era of Healthcare Provider Data Transparency

The consumerization of healthcare is making provider data transparency a priority for CMS.

Healthcare reform has brought many changes to the healthcare landscape, and the consumer is becoming a key player in this new era. The consumerization of healthcare has brought to light the many challenges of delivering user-friendly, accurate provider data. Data inaccuracies in provider directories have been well publicized. Provider networks are under the spotlight now, more than ever. New requirements focus on increased provider data transparency; allowing consumers to access better information about the providers included in a health plan.

In February 2015, the U.S. Department of Health & Human Services released the Final 2016 Letter to Issuers in the Federally-facilitated Marketplaces (source). This letter provides guidance to qualified health plans (QHPs) and stand-alone dental plans (SADPs) to help them participate in the 2016 marketplaces. One of the most contentious topics covered is network adequacy, particularly, the collection of provider directory information. CMS is requiring qualified health plan (QHP) issuers, including SADPs offering plans, in plan years beginning on or after January 1, 2016, to publish information regarding provider directory and formulary data in a machine-readable format on its website in an HHS-specified format (source).

We wanted to learn more about the impact this requirement will have on the healthcare landscape, so we spoke with Matthew Mellor, CEO of Strenuus, to shine some light on this impending change.

How do you think the machine-readable file requirement from CMS will change the healthcare industry?

I think that’s still unknown. We will see some timely compliance, some non-compliance, and I think we will eventually see some pushback on the provisions of the machine-readable files. We will eventually end up with something that meets the transparency goals of the machine-readable files, but something that may look and feel different than what we have today.

Do you think this sort of requirement will spread to other lines of business (currently it applies only to federal exchange states)?

I think this program will probably be a test bed for how useful this type of information is and whether it creates more problems than it solves. If the end result is creating better value for the consumer, I think it is likely we will see it in other areas with a controlling entity, like CMS, setting standards.

Do you feel health plans will be capable of meeting these demands?

Health plans are getting a lot of pressure from different directions resulting in resource strains on their IT departments. This is not an insignificant task for them to accomplish in a short time frame. I think the biggest challenge will be in order to do it right and on time, they will have to decide what other priorities and initiatives within the organization are less important or will need to be given up.Companies like Strenuus are able to intermediate and help with the process, adding value and meeting these needs along the way. From our perspective, we would like to offer health plans greater visibility into who is using their data, how it is being used, and provide safe guards around the data.

How will this change things for consumers?

I don’t think it will help consumers directly, but it will help third party healthcare IT companies that are trying to build applications to serve the consumer better. We don’t know what that will look like at this point. With transparency data that has already been released, like cost data and physician relationship information, there was a flurry of new companies building tools around the data.

Speaking of third party companies, what are some of the issues that could arise from various third parties trying to work with this data?

There are two big issues. Despite efforts to create a standardized format, one of the underlying challenges is that the data being delivered has no consistent standards for the way information is stored from one plan to the next. The other issue is being able to pull information together in such a way that it is meaningful and useful to consumers. Having a single file format but no standards for the “right” way to store the underlying data means that you are only going to cause additional confusion for consumers.Like many things, the devil will be in the details. We know from the work we do, the nature of the data that is captured and maintained by health plans does not make it easy for a third party to analyze the data and provide meaningful information for consumers. The requirement for machine-readable files is nothing more than specifying what kind of container you want the data to live in, but the contents of the containers remain unchanged. When they are combined, the inconsistencies between the containers’ contents are still there. Minor variations can turn into major issues. This is where a company like Strenuus comes in to clean, match, and manage the data to ensure it is used correctly and accurately.Learn more about how Strenuus can help you navigate and fulfill the new CMS requirements with its proprietary technology, Provider Nexus io, by clicking here.

Healthcare reform has brought many changes to the healthcare landscape, and the consumer is becoming a key player in this new era. The consumerization of healthcare has brought to light the many challenges of delivering user-friendly, accurate provider data. Data inaccuracies in provider directories have been well publicized. Provider networks are under the spotlight now, more than ever. New requirements focus on increased provider data transparency; allowing consumers to access better information about the providers included in a health plan.

In February 2015, the U.S. Department of Health & Human Services released the Final 2016 Letter to Issuers in the Federally-facilitated Marketplaces (source). This letter provides guidance to qualified health plans (QHPs) and stand-alone dental plans (SADPs) to help them participate in the 2016 marketplaces. One of the most contentious topics covered is network adequacy, particularly, the collection of provider directory information. CMS is requiring qualified health plan (QHP) issuers, including SADPs offering plans, in plan years beginning on or after January 1, 2016, to publish information regarding provider directory and formulary data in a machine-readable format on its website in an HHS-specified format (source).

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