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With 2024 in the rearview mirror, the leadership team at 1upHealth is looking forward to the improvements coming to healthcare data exchange in 2025 – with payers leading the charge.
Here are our predictions for the 5 key trends in healthcare data exchange for 2025.
#1 Payers will rethink their approach to data exchange – and change how they communicate with patients and providers in the process.
In 2025, the software upon which our smartphone economy is built – namely APIs (application programming interfaces) – will force payers to rethink the way they exchange data within their “four walls” and with external organizations, along with the format of that data.
This API + FHIR approach will be driven by CMS-regulated health plans needing to 1) comply with the CMS-0057 final rule and 2) prove results and provide reporting as part of Medicare Advantage (MA) and managed Medicaid. Forward-thinking MA and Medicaid plans will be working overtime to harvest data and influence their Star Ratings using APIs.
A modern digital strategy, whether it’s for a merchant like Amazon, a service provider like a bank or airline, or a media company, relies on easy access to websites via smartphones and targeted outreach via messaging or email timed to optimize success. For payers that means thinking about what to “say” to patients and providers, and how to “hear” from patients and providers. More and more, payers will rely on APIs to enable more effective communication.
#2 Leaders will be separated from laggards based on how they lean into CMS-0057 regulations.
Payers who look at the data exchange requirements of CMS-0057 as a path to a competitive advantage will take the lead.
For example, if you lean into Payer-to-Payer Data Exchange and set up capabilities to understand the utilization history and care patterns of new members, and then develop network design programs or deploy your care management to influence each member’s behaviors, you’re going to take the lead.
If you replace your “proprietary flat file every 30 days via SFTP” with an on-demand Provider Access API, you’ll be leading.
All organizations who take a “just check the box” approach will be on the losing end of this transformation opportunity.
#3 Expect to hear a lot about MA plan spend and the underlying performance data in 2025.
MA was a huge news story in 2024. Several MA plans sued CMS over their Star Ratings – and won. Numerous health systems dropped MA plans. The number of health plans achieving 5-Star Ratings dropped to a low of seven. Meanwhile, many MA plans lost money, and several shuttered (or are in the process of shuttering) their businesses. All while CMS pays 22% more to MA than FFS.
We expect MA will be an even bigger news story in 2025. As the new administration and narrowly divided Congress take over in 2025, we can expect the government to have an even bigger focus on MA (with its big price tag and continued growth) and its similarly capitated Managed Medicaid programs. In addition, MA plan payment rules will almost certainly materially change in 2025.
#4 Successful plans will totally revamp their IT infrastructure to become far more capable in managing the clinical data needed to successfully manage care.
The days of trying to control plan spend and ratings with only claims data are coming to an end. Increasingly, the winners will use clinical data to both measure and improve performance.
Star Ratings, in particular, can make or break a plan. Ultimately payment levels are a data play, and that data will increasingly include rich clinical data. Additionally, it’s important to understand scores are relative. If one plan uses more clinical data and gets a better score that means that other plans that don’t use clinical data are more likely to get a lower score. The need to “get clinical” will also extend into managed Medicaid, which has so far been buffered by individual state policies.
#5 In 2025, the industry will focus on transforming payer-provider data exchange with real-time computational workflows.
Despite the availability of FHIR APIs and advanced technology, progress towards a truly interoperable healthcare system in this country has been held back due to mistrust and competitive dynamics amongst stakeholders.
However, a shift towards free-market solutions is emerging, where payers and providers will increasingly demand real-time, standards-based data exchange in their value-based contracts. Organizations that leverage this shift to gain competitive advantages – by replacing outdated methods of data sharing with modern, on-demand FHIR API access – will lead the way.
While challenges persist, financial pressures on MA plans and the industry’s growing recognition of business impacts are expected to drive meaningful transformation of payer-provider data exchange this year.
Powerful market dynamics will drive the industry forward this year.
Buoyed by our purpose of making healthcare better for all though better data and powerful market dynamics moving the industry forward, the team at 1upHealth is looking forward to an exciting and impactful 2025. We look forward to working with others in the industry to hasten progress. Onward.
