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CMS released an update to its series of interoperability focused regulations – most recent being a proposed update to the Interoperability and Patient Access Final Rule. At 1upHealth, we’re dedicated to unpacking industry developments such as this, which is why we brought together a team of in-house experts for a webinar to help break down key themes about the ruling, share their points of view on what’s next, what you can expect, and how to prepare.
The Goal of CMS’ Updated Regulation
First and foremost, it’s important to understand the strategy behind CMS’ update for the proposed ruling. It can feel daunting to navigate the ever changing winds coming out of D.C., but our experts are here to help make sense of the regulatory changes and what they mean for the industry as whole.
“If you had to put a word on all of CMS’ requirements it’s ultimately all about transparency – i.e. they’re about getting data into the cloud, computing on that data, and utilizing that data for transparency across the whole healthcare system,” shared Dr. Don Rucker, Chief Strategy Officer at 1upHealth and former ONC National Coordinator.
Ultimately, the goal of this transparency is to change the American healthcare system for the better, which is obviously a lot easier said than done. As Dr. Rucker said, “as we all know, the massive system that is American healthcare will require extensive structural and technological changes in order to improve.”
Understanding the Three Classes of APIs
As part of CMS’ strategy to achieve the above objective, they have defined three classes of APIs. Dr. Rucker broke these APIs down for our audience as the following:
- Payer to Payer – Payers must be able to send, receive, and incorporate enrolled member data with another payer when permitted by that member.
- Payer to Provider – Enables payer’s to have the broadest possible overview of care between providers, enabling a totality of care for the patient.
- Payer to Patient – Focuses on understanding and enabling a patient’s care and their ability to shop for that care among different payers.
While they are technically different, according to Eden Avraham-Katz, General Counsel at 1upHealth, these three APIs have a lot of overlap in the how, who, and what.
- How – The mechanism/standard (FHIR®) that enables the exchange of data.
- Who – All three APIs affect Payers.
- What – The classes of data that need to be exchanged – clinical, claims, encounter data, and prior authorization data.
How Interoperability Strategies Come into Play
Throughout the webinar our experts helped unpack how CMS’ strategies point to interoperability as a key goal to achieving the objective of transparency throughout the healthcare industry. One way we can see this is through CMS’ continual emphasis on payer and provider interoperability and data exchange through the use of FHIR, as well as the value of clinical and claims data being available to both parties in furtherance of improving care. Eden cautioned, “while 2026 might feel far away, time flies in our industry and there will never be a period without challenges that require energy and effort to solve.”
Eden continued by saying “if you’re looking at FHIR and these CMS compliance requirements as a problem you’re looking at it the wrong way. FHIR isn’t a problem to solve, it’s a solution to take advantage of. It is absolutely key to be thinking about how to leverage FHIR today to optimize your workflows to make everything you do more efficient.”
Ultimately, as made evident by Dr. Rucker and Eden throughout the webinar, the value of being able to pull in external data using FHIR APIs and then using FHIR as a standard to normalize that data consistently so that you can actually use it as one holistic data is paramount. “The value in that action alone in terms of administrative workflows is astounding,” Eden said.
CMS is making clear that by taking advantage of FHIR’s capabilities today you will not only gain compliance, but you will get ahead of the curve in terms of improving your overall operations and capabilities.
The Uniqueness of the Provider Access API
Dr. Rucker and Eden spent time discussing how CMS is pushing the industry to understand the benefits of implementing the changes outlined in the ruling. “It’s not simply about meeting the requirements and achieving compliance, but rather it’s about enabling a new way of working,” said Dr. Rucker.
For example, the Provider Access API is one of those elements that isn’t just about the tactical implementation, but really strategic implications as well. Eden helped explain that what’s so interesting and unique about the Provider Access API is that it includes an opt-out model. Both the Patient Access and Payer to Payer APIs have an opt-in model, meaning that for data to be exchanged an individual has to go in and grant permission to have that data shared. With the Provider Access API’s opt-out model, data is exchanged unless an individual expressly requests that it isn’t.
This is an important nuance to see because getting individual consent tends to be a roadblock for data sharing across the healthcare industry.
How Payer to Payer is Affected
Of course, it’s imperative to know how CMS’ actions affect not only the industry as whole, but payers themselves. Eden and Dr. Rucker explained how the core changes we’ve seen from CMS’ proposed regulation in December are particularly interesting to point out because they’re actually indicative of the shift in tone that CMS is taking as a routine center of interoperability. Two big areas we’ve seen recent expansion on are impacted payers and data elements. For example, originally Payer to Payer was just supporting clinical data exchange – now we’re seeing that being far more expanded to all four of those data elements we referred to earlier.
In addition, the original layout of Payer to Payer didn’t really tie into Medicaid and CHIP. Now it does and consequently has been expanded to include even more payers than before. This in turn is likely to increase the visibility and coordination on the state level.
Eden shared another interesting point to consider on how payers are affected by this ruling. She stated that, “even though Payer to Payer is still an opt-in model, we’re seeing a lot more requirements on the payer here to be an active participant in this process.”
As Eden helped break down for the audience, the original ruling was worded as such where when a member requested their data you had to share it, whereas now it’s more so worded along the lines that payers have to have an administrative process made available at the time of enrollment for any member to identify previous payers to opt-in to data sharing. “While this is still an opt-in model, it feels much more like an active opt-in and is an important differentiating factor to consider between Payer to Payer and Patient Access.”
Key Takeaways
Dr. Rucker and Eden summarized the key takeaways as the following:
- FHIR is here to stay, and without FHIR, interoperability is not really possible
- While 2026 might feel far-off, there is a lot an impacted payer has to do to be fully compliant by 2026 and it is highly unlikely that they will be successful if they wait until 2025 to do it.
- The value of FHIR can also be leveraged today to support workflow optimization and data interoperability, so waiting for 2026 could actually be costing you money.
- CMS continues to emphasize payer and provider interoperability and data exchange, along with the value of clinical and claims data being available to both parties in furtherance of improving care.
- CMS is definitely starting to be more thoughtful about Social Determinants of Health (“SDOH”), as well as mental and behavioral health data, as evidenced by the RFIs included as part of the Proposal.
To learn more, view the Breaking Down the CMS Final Rule: Takeaways and Actions webinar.
