Taking the Long View on Interoperability

By Mike Penich, Partner, Cumberland Payer Division

Move quickly, but don’t forget the big picture

It is crucial that health plans move quickly to meet the Patient Access and Provider Directory API requirements given the January 1, 2021, deadline for compliance with enforcement beginning six months later. While meeting the minimal requirements is the urgent priority, health plans must adopt a strategic long-term view of interoperability in order to maximize future benefits.

Focus on the benefits

I know what you are thinking: “Wait, there are benefits to these regulations?” It’s common to have concerns that a new regulation is just going to put an additional burden on already strained resources, time and money without any tangible benefits on the back end. However, we believe interoperability creates a huge opportunity for health plans to see real value if implemented with the long view in mind. Future potential benefits include:

  • Improved Member Engagement
  • Reduced Costs – for both the Member and the Health Plan
  • Better Medical Adherence
  • Improved Care Coordination

Position your organization to realize the value of interoperability

Interoperability business objectives and opportunities can and will change over the coming years. But it’s important to begin strategizing now about where you want to be. For example, getting to a portable Longitudinal Patient Record (Health History, Social Determinants and Remote Monitoring) for your members will lead to cost savings and quality of care improvements. Care coordination can be greatly improved as new members bring their data with them as they switch health plans or providers. Interoperability is a building block for these and other capabilities. To ensure you are positioned for success in the future, Cumberland recommends the actions below.

Treat interoperability as more than an IT project. Interoperability is not just an IT compliance project; business stakeholders need to be engaged and understand the impact of interoperability on your business and your members. Think about what your long-term objectives are related to lowering costs and improving quality of care, and then develop an organizational roadmap for how you’re going to get there.

Educate and support your members. Member data is going to be exposed to third-party applications; these applications are now “competing” with your organization to engage with your members. Based on these changes, you need to refine your strategy on member engagement and determine how you’ll educate members. Consider developing your own application for your members’ portable health records. Enhance your member experience beyond what the rule requires, build loyalty and differentiate your organization by enabling new capabilities for your members.

Choose a scalable, flexible and comprehensive technology solution. Keep in mind that any interoperability technology solution is an initial step, not the end of a long journey. We know payer-to-payer data sharing will be required by 2022 and additional regulations are likely to follow, so any tech solution you select must be flexible and scalable. If building a solution internally, ensure you have the bandwidth, knowledge, and ability to respond to new or changed regulations in the years to come. If utilizing a vendor solution, ensure the technology will meet all components of the regulation and will enable your requirements that go beyond the rule. While many vendors offer free APIs, a comprehensive solution needs to account for much more than that, including third-party app management, member consent and potentially data clean-up.

Consider the changing competitive landscape. Be mindful of changes to the competitive landscape. Aggregated data from members can shed light on your and your competitors’ provider networks, benefits and pricing information. What risks or opportunities will that create for your organization? How will big tech or other disruptors capitalize on these regulations? Third parties are likely to seek out ways to incentivize members to share data in order to leverage that data to further disrupt the industry.

Ready for next steps?

Cumberland can help you define and implement your organizational strategy by leveraging our business consulting services. If you’re interested in learning more about this or Cumberland’s other interoperability solutions, please email me at info@cumberlandcg.com.


This is the final post in a three-part series on the new ONC and CMS interoperability rules and requirements. For details on the new rules, please read our post
What Are the New CMS and ONC Rules for Payers? For tips on how to get started, please read our post What Actions Should Payers Be Taking Now To Meet ONC/CMS Interoperability Requirements?