The New API Economy (Now With Interoperability!!!)

flying cadeuciiConsumers know that their primary care doctors don’t talk to their specialists, who don’t talk to their pharmacists, who don’t talk to their insurance providers. The rise of consumerism in healthcare may be in its infancy, but according to research recently released by Xerox, a full 64% of consumers wish their pharmacist, healthcare provider, and insurance company were more connected regarding their health.

Consider your most recent travel experience. You probably used a website like Expedia.com to look up flights, hotels, and even rental cars. With all the relevant information displayed conveniently (and often beautifully) side-by-side, you were probably able to make an informed decision and instantly book the exact travel package that suited your needs.

Now imagine your most recent healthcare experience. Scheduling the appointment was probably a painful logistical balancing act, accompanied by terrible hold music. You likely had to find and present an insurance card, possibly even filling out another set of insurance forms and a health history for the thousandth time.

After the appointment, you doubtless received an excessive number of mailings that were maybe bills or maybe not.  At this point, you might even still be unsure how much you owe, why you owe that amount, and what you can expect for your next appointment.

And you’re not the only one suffering. While all this is happening, an equally painful parallel process is taking place behind the scenes, completely unbeknownst to the consumer. It starts with the care provider, who must electronically or sometimes even still manually bill the insurance company. The claim then passes from the provider to a clearinghouse, where it is checked for errors and compatibility with payer software. When the claim finally does get to the payer, the majority of them are still faxed back to providers for more information: was the procedure medically necessary? Is a referral required? The physician’s office corrects the claims and sends it back through the same pipeline towards approval.

This process is a massive headache for everyone involved. Providers find themselves with huge amounts of extra administrative work, while consumers are completely shrouded from the billing process. It’s almost like walking into Nordstrom’s and shopping blindfolded, while trying to stay on a budget. It’s just not possible.

Thankfully, there’s a better way. Healthcare can look more like booking your next vacation — a more personalized, consumer-friendly experience, at a better price too. The first step in getting there is Application Programming Interfaces, or APIs. At a high level, APIs let data to break free of their silos, allowing it to move freely, and enabling the interconnected experience we all enjoy when booking travel. If properly used and widely adopted in healthcare, APIs will be transformative.

What’s the API model?

APIs and their use in healthcare are on the rise for a number of reasons, including the consumerization of healthcare, the explosion of smart devices, and the arrival of a generation of tech-savvy consumers who want access to healthcare resources and information in the same way they have access to everything else in their lives—anytime, anywhere, and from any internet-connected device.

In order to better serve these tech-savvy consumers, who are increasingly charged with managing their health spending via high-deductible, HSA plans, payers and providers need to be able to exchange information in real time. Take the previous simple scenario of a fairly standard visit to your healthcare provider. In an API Economy, consumers won’t need a health insurance card or to fill out any paperwork. All the relevant information can be accessed by the appropriate stakeholder on demand. Providers will be able to check eligibility and co-pay by accessing a patient profile, for example. Once the visit is complete, the EMR can trigger the claims process, sending all necessary medical information directly to payers. Claims will be immediately adjudicated in one fell swoop. What’s more, consumers will know at the point of care how much they are paying and why, and what any additional prescriptions, referrals, or follow up care will cost.

With the right APIs in place in healthcare, the need for administrative questions is essentially eliminated because every stakeholder would have access to all the relevant data. The type of data exchange described in this example is fairly basic, but the API infrastructure that will allow us to eliminate countless administrative headaches – incorrect patient information, incorrect codes, duplicate claims – is the same infrastructure that will allow us to create advanced analytics and innovative service models. Furthermore, the advanced security implicit in an API model also means that even as consumers’ valuable protected health information moves freely about, so to speak, it remains encrypted and secure.

The fact that we haven’t moved even further in this direction is especially confusing given the fact that transitioning to an API model is not necessarily an intimidating or complex process, technically speaking. Old and new technology investments can be gradually bridged, and companies like PokitDok, with its API platform, mean organizations are spared the need to build from scratch. The pieces are in place for this transformation to happen, it’s only a matter of time.

What would the API Model mean to the industry?

A shift to an API model would have at least two major impacts on healthcare:

Free the data for value-added, consumer-centric innovation and applications. With an API infrastructure, everyone will have equal access to data, meaning companies will be forced to innovate on the value of the services or analytics that can be built on top of that data. For example, we’ve already seen some companies like Castlight Health, Amino, and Grand Rounds take disparate, accessible (albeit in a difficult, not always API-enabled manner) data sources and create new dashboards with new metrics that consumers are actually interested in using. Moving forward, APIs can deliver these types of innovations in spades.

Improve customer service relationships with healthcare payers. Imagine a typical call to a customer service department, but the agent on the phone has a new set of information at their fingertips, like the caller’s type of insurance, deductible and copay, and a list of physicians within the appropriate proximity. An API model can deliver this type of informed call center and lead to highly personalized client engagement.

Adopting an API model in healthcare gives an outdated system the versatility and flexibility it needs to tackle some of our most entrenched problems. APIs can transform insurance companies from passively paying claims to actively helping its members lead healthier lives. APIs can also transform customer care in healthcare, making it more reflective of the experience we all enjoy in retail, for example. But perhaps most importantly, APIs can support more connected, more informed consumers and providers, resulting in the higher quality care that we all deserve.

Tamara St. Claire is Chief Innovation Officer for XEROX.

Categories: Uncategorized

4 replies »

  1. Well, there you go. Xerox did a study and God has spoken. We must now move to what? An API model? Yes, that will fix it all until it needs to be fixed immediately after it has been implemented. I love business people and their language. Words like stakeholder and consumer-centric sound inviting. How about a methodology relatively devoid of codes and the need to check eligibility? Impossible? No. It only requires imagination which is in short supply in Washington, DC. http://www.fixthebus.com

  2. Not to be too harsh, but this will happen with the herd of unicorns run down my street.
    There is no incentive for this, payers want to delay and deny claims, they want all the extra hurdles, they want 20 minute holds on the phone for preauth and billing denial fixes and every other meaningless hurdle to getting paid. There is just no way to squeeze more efficiency out of this current system, API or not. There are ENORMOUS security challenges with APIs, including propagation of misinformation, wrong info, wrong patient, breaches that involve massive data exposure. Nothing short of another mega billion dollar program could make this work. Look even the VA and DOD cannot promise interop over the next 5 years, and that is after 14 billion in funding and they share the same batch of a million patients or so, all within the same US gov. So good luck making the Cleveland Clinic API-it-up with University Hospitals of Cleveland. Right. So in reality, the best way to fix all of this is something I am not prepared to do just yet, but its take EVERY single person out of my way, just be a cash only practice. Yep, no preauths, no claims, no billing issues, no supporting an entire industry of click counters, numerators, denominators, etc. Just back to me and my patient. That is really the final answer.