The Centers for Medicare & Medicaid Services (CMS) recently called for a request for information (RFI) to strengthen their efforts advancing interoperability goals while tackling process challenges related to prior authorization to increase efficiencies in healthcare. This proposal builds on the “technology foundation that was established in the May 2020 CMS Interoperability and Patient Access final rule” and together, “these policies would play a key role in increasing efficiency, reducing overall payer and provider burden, and improving patient access to health information,” according to the CMS.
Technology advancements are integral to the advancement of healthcare, yet often policy decisions are made without including the voice of independent PCPs. This process means that one of the most powerful forces for health and wellness in America, primary care, gets left behind.
Elation Health is fiercely committed to advancing the national landscape for high-value primary care. That’s why we prioritize advocating for inclusive policies on behalf of the community of physicians and practices that we’re proud to serve. Below are excerpts from the letter that Elation leaders sent to HHS, which recommends a more inclusive approach to interoperability and prior authorization processes to more accurately reflect the full spectrum of healthcare providers. These excerpts were delivered on behalf of Elation CEO and Co-Founder, Kyna Fong; our Director of Primary Care Advancement, Dr. Sara Pastoor; and our Principal Solutions Engineer, Andrew Talbot.
“Independent PCPs tend to miss out on regular improvements in electronic health record and information exchange technology. While large provider systems have multi-billion-dollar budgets to pay for advanced health IT and exchange systems, independent practices generally have only received small stimulus grants in the last decade through the now-expired Meaningful Use program. The entire healthcare system benefits when PCPs participate in electronic information exchange, using standardized, interoperable systems. HHS and CMS regulators should pay special attention to the health IT and interoperability needs of these critical PCPs and provide additional funding and support to get them connected to these resources.”
Recommendations to Reduce Prior Authorization Burden in Primary Care
“Indeed, any regulatory suggestion to make prior authorization faster and more technology-enabled, like ePA, may create a perverse incentive to add more prior authorization requirements to an already overburdened system. Rather than implement requirements to move prior authorization to standardized electronic interfaces, or APIs, we should focus our energy on eliminating prior authorization requirements altogether. As we have described, primary care is the only medical discipline that can turn $1 into $13 and realize better health outcomes in the process. Prior authorization and utilization requirements are entirely inappropriate in these settings.”
Elation Health is acutely aware of the daunting administrative burden experienced daily by primary care practices. A significant contributor to this burden is the prior authorization process. Efforts by ONC to automate and standardize prior authorizations are not enough to alleviate the related delays in care and distraction from meaningful clinical activities created by these inappropriate utilization management efforts in primary care. Comprehensive reform is needed.
“CMS can be most helpful to health IT developers serving the primary care community by reducing uncertainty around regulatory feature development and helping to drive confidence in development of new interfaces and standards to promote interoperability. Elation’s PCP customers depend on us to support the high value primary care that they deliver with best-in-class technology and enablement solutions. The features and functionality we deliver must prioritize their needs to successfully treat patients and populations under their care. When 15-20% of our team at any point in time is diverted to respond to new regulatory requirements, it means we are slower to respond to the needs of customers on the front lines of primary care.”
Elation is concerned about the ongoing lack of minimum standards for electronic interface requirements, including the lack of mandatory adherence to industry-identified implementation guides to ensure high quality data exchange between payers, providers, and patients. We recommend the implementation of a mandatory test system to ensure all developers meet the same data standards requirements, while improving clarity and speed of development.
Unfinished Business with Patient Event Notifications
“We strongly encourage CMS to strengthen education and enforcement efforts of this rule to improve care outcomes.”
Finally, as a champion and technology enabler for high-value primary care, Elation is concerned that the CMS-9115-F Admission, Discharge, and Transfer patient Event Notification Conditions of Participation rule, which was finalized in 2020, has not been fully implemented. Affected hospitals are required to share patient event notifications with PCPs, but our experience has shown that many hospital providers have not yet changed their behaviors to ensure timely, complete notification of event information to enable primary care to manage the care of these patients in the outpatient setting.