Host Pooja Babbrah, Senior Consultant and Payer and PBM lead kicked off the episode focused on prior authorization, reducing burden and why working ahead of final federal rules isn't as risky as you might think. Pooja filled in for Ken Kleinberg, who is out of the office on an extended grand adventure. Pooja was joined by co-host Jocelyn Keegan. They welcomed guest, Danny Brennan, Executive Director and CEO of the Massachusetts Health Data Consortium (MHDC). Jocelyn introduced herself and shared that she's literally done hundreds of hours of educating and evangelizing out in the industry about the work that is happening within HL7 from the FHIR community. She went on to explain that while doing this industry education, John Kelly, now retired from Edifecs, recommended she meet Denny Brennan explaining that Denny literally knows everyone in Massachusetts. Jocelyn continued to say that she has gotten to know Denny and the MHDC team over the last four years and has learned they are super smart, focused industry veterans filled with a lot of pragmatism about how the industry can get things done. Denny Brennan then introduced himself, sharing that he's been the executive director of MHDC for the last 10 years. Denny explained that he spent the prior 20 years evenly divided between consulting and technology services. Denny added that MHDC has been around since 1978, so going on 45 years. Denny responded to Jocelyn's point about knowing everyone, by saying0 that getting to know everybody in Massachusetts would have been an extraordinarily difficult thing if he didn't work for MHDC. Pooja then asked Denny to tell us more about MHDC before the transition over to the discussion topics. Denny shared that MHDC is comprised of everyone in the health data community in Massachusetts, some regional and some national players but that the center of gravity is the Commonwealth of Massachusetts. MHDC came about because the state, health plans and providers wanted an unbiased organization focused on health data with less focus on technology. Denny explained that nowadays technology and data are so intertwined that industry stakeholders end up moving between them more effortlessly than historically. The mission of MHDC is to create a patient centered health data system that enables the kinds of cost reductions, burden reductions, improvements in quality of care, enhancements in the patient experience, improvements in equity and access that are not possible when enterprises try to do this on their own. The MHDC motto is to start small, to start at the individual, and work from there. MHDC approaches this in a few different ways. One is to assist payer and provider members in understanding data governance in this new world. What does it mean to comply with regulations? What does it mean? What is FHIR? What does it mean to move to a world where patients are banishing their health data from the device and are connected to any and all of the services that help them achieve health? Denny continued to say that governance is just a start, to help people understand what's coming. Why? What happens if their organization doesn't do it? What happens if they do? MHDC offers exchange services that operate to provide payers and providers the ability to share data with each other. MHDC also uses the exchange service as a launchpad, or a test kitchen, to explore how to automate real time processes, like making real time prior authorization a reality. MHDC also offers a web-hosted analytics service called Spotlight to organizations. Finally, Denny explained that MHDC is also called in to support consulting efforts to help organizations figure out how to implement some of these more modern approaches to data exchange. Pooja responded that she loves the idea of the test kitchen role. She then asked him to expand more on the test kitchen idea, describe why the Massachusetts location is so important, and why prior authorization seems to be such a central focus on MHDC. Denny responded by saying that the test kitchen concept is a reflection of a personal bias of his, but also that healthcare is an industry that is governed in many respects by followership. He added that nobody wants to be the first to fall off the pier and land on their heads. They want to see other organizations do that, do it successfully, and then others will follow creating a tidal shift in adoption. Denny emphasized that it's important that organizations recognize that they won't know everything when starting out and won't know where a project may end up. He went on to explain that rather than ready, aim, and fire, the MHDC approach is more aim, fire, get ready again, aim, fire, get ready again. Interoperability is an iterative process. Denny changed analogies and said that the industry doesn't have to try to eat the entire elephant and to just take one bite at a time.Denny further explained that the test kitchen is a way for organizations to start with what is known but to reduce the risk so an organization can experiment without basing major business operations on it.Denny transitioned to talk about why prior authorization is a major focus of the work that happens in the test kitchen. He explained that it's because everybody hates prior auth. PA involves patients, physicians, and health insurance plans. Denny observed that it seems everyone would like to do it better but has a different idea about how to do it better based on their perspective. The MHDC approach is that this is a business process that, if automated, will enable organizations to automate other things that are far less complex. The work undertaken to automate PA could take a big chunk out of what goes into avoiding another industry focus, surprise billing. Denny stressed that MHDC is a consortium and brings members, who are both competitors and partners, into the same room to tackle what is essentially infrastructure challenges they all face. This type of collaboration allows MHDC to learn what their issues are, what their fears are, what their concerns are and we can start addressing those right up front. Pooja then shifted the conversation and asked Denny to explain the Automation Advisory Group including its maturity, how many members are participating and whether listeners can expect any reports or other outputs.Denny explained that the Automation Advisory Group is being done in partnership with the Network for Excellence in Health Innovation (NEHI) and the effort is one side of a two-sided coin that MHDC is using for prior auth. The other side is prototyping, a real prior authorization implementation in an automated compliant, industry standardized way so it can be replicated and scaled across multiple payers and providers. MHDC is starting with one payer and one provider, one technology company to take a bite out of the first piece of prior authorization sticking to the rules, sticking to the standards and learning from the experience. The Automation Advisory Group is made up of about 40 approaching 50 individuals, representing payers, providers, hospitals, medical groups, individual physician practices, vendors and policy makers, that will be assembled over the course of the next year or two. Denny went on to say that MHDC's strong suit is bringing together a coalition, a consortium of representatives from across the industry in Massachusetts and nationally to tackle problems together. Government participation includes Center for Medicare and Medicaid Services CMS, the Office of the National Coordinator (ONC), Massachusetts Executive Office of Health and Human Services as well as the Health Policy Commission. The effort is being funded by a mix of vendors, technology services companies and the Health Policy Commission. The goal is to take the Commonwealth of Massachusetts and automate prior authorization statewide in two years which will require legislation. Regulators were brought to the table so they can get everything they need to create a meaningful law. The idea is that this law should not just be a stick, but also offer carrots in the form of implementation and technical assistance. Jocelyn responded to Denny by saying that this Automation Advisory Group is providing a great test bed that allows organizations to see how certain products and technologies can be leveraged but to also think about the business processes that will need to change. Joce explained that there are hard decisions about what happens when new technology is applied in the real-world. Jocelyn continued by saying that the industry is at a sea change where standards have a critical role. Jocelyn then expressed how thankful she is for organizations like MHDC who are willing to be forward first and that she wishes there were more organizations out there doing this kind of work and recognizing that there is a competitive advantage to starting down the path early. Jocelyn went on to say that this work is a set of building blocks putting together the right technology with the right processes to solve problems rather than checking a regulatory box. Pooja asked Denny whether he felt like it was risky for organizations to move toward automating prior authorization before the PA and burden reduction rule is re-issued. Denny responded that there is always a risk at being out in front, but the risks are bounded by the fact that you stub your toe in a relatively circumscribed implementation and you move on. The downside risk of not moving forward is you don't know what you don't know and can be caught flat-footed when a project has a longer lead time than expected or requires expertise or resources an organization doesn't have. Denny further explained that the emergence of acute need for telemedicine during the pandemic has made the use case for innovation more clear in some cases which helps make the decision to act a little easier. Denny added that the risk of a failure to implement is much higher than being out in front. Denny continued by saying there is a convergence of consumer demand for information and transactions to be more real-time and at their fingertips in the same way they get it from their bank or shopping on Amazon, policy to drive interoperability and standards and technology to enable the shift. Denny concluded by saying that consumers will find the payers, providers and tools that meet their needs so if an organization doesn't act, there is a huge risk of losing customers, members, patients to competitors that have done the work to be interoperable. Jocelyn responded by commenting on the unique Massachusetts landscape due to the competitive payer market. There isn't one predominant payer that owns most of the market. Jocelyn went on to say that another thing that is different now is that CMS and ONC are looking to the industry to lead, they are watching and listening to what is happening and making policy to spur the rest of the industry into the direction of what seems to be working which is APIs. Jocelyn expressed her complete agreement that there is more risk in doing nothing rather than taking on incremental projects and incurring some risk but moving the needle. Jocelyn continued to say that we know these projects will take longer than people think and that means that those choosing to do nothing and wait policy to force change will be at a huge disadvantage. Pooja followed up by asking about the seemingly increased coordination between CMS and ONC in their policy making and wanted to know whether Denny felt this coordination made their overall rulemaking stronger and more robust. Denny responded by explaining that MHDC knows Micky Tripathi, the National Coordinator well because he is a Massachusetts native and used to manage the Massachusetts eHealth Collaborative. Denny continued by saying that Micky knows the provider side of the business extremely well, he understands APIs and knows technologies. Micky also knows moving providers to interoperability is an entirely different exercise than moving payers to interoperability. He also knows there are deep cultural shifts that must happen. Denny went on to say that because the industry initially built enterprise level electronic medical records, health data was sort of feudalized and in many ways, providers were incentivized to hold on tight to their data. This enterprise level approach did not develop the kind of agility required for interoperable data exchange that will better support patient care but the industry didn't know then what it knows now. Denny continued to say that with respect to ONC and CMS that when the first rule was published from CMS about prior auth. The rule was groundbreaking because it brought the agencies together and put the patient squarely in the middle. This was a different approach from focusing on the bickering that had been happening where providers arguing they weren't paid enough and payers arguing providers spent too much. CMS and ONC, rather than saying payers and providers start getting along, they said, you've forgotten about somebody, the patient, the consumer, the member, the person, the individual. There are 330 plus million of them and they are a critical part of solving healthcare problems. Denny concluded by saying that neither payers or providers want to seem like they don't care about the patient and ultimately consumers need access to information to help make the best healthcare decisions. Pooja expressed her agreement that the patient should be the focus and asked Denny to describe his future vision of healthcare. Denny responded by saying that he believes that having patient advocates at the table will help get us where healthcare needs to be. He clarified by saying that by patient advocates he means people who can give voice to the type of data that is most needed by patients and their caregivers to make the best decisions. He explained that health plans and health systems in the healthcare delivery business may lose sight of those granular patient needs because they are dealing with administration, regulations, and compliance. Denny continued to say that another movement that is huge is health equity. With equity the industry doesn't yet know what to measure to make an impact. Denny recommended that everyone start small instead of trying to set up a great big equity initiative. Denny added that instead of trying to envision the perfect equity solution, which is impossible to envision because everyone is different, start with something that supports the disadvantaged members of your own community. Try out something on a smaller scale, see what works and build on it, just take a bite out of the problem.In closing, Pooja asked if there is a final message or call to action that Denny wanted to pass along to listeners. He responded by saying to get outside of your organization, meet with business partners and competitors and recognize that many of the challenges they all face is about infrastructure not sources of competitive differentiation. He went on to say the industry needs to lay the railroad tracks or the highway system or the power grid. He expressed that the industry is building something that will make it possible for us all to live better and do business better and care for patients better than before, but it can't be done in silos. He encourages the industry to come together. He continued by saying that as organizations start working on things and start winning, however small, people will start coming to those organization because they've done something that hasn't been done elsewhere. Denny concluded by saying that organizations just need to take a step, however small, and to not forget about the patient. Pooja concluded the episode by thanking Denny for joining the podcast as a guest and thanking Jocelyn for being a fun and informative co-host along with a reminder to any new listeners that they can find The Dish on Health IT on Apple Podcasts, Spotify, Healthcare Now Radio and the Podcast Channel and that videos are posted on the POCP YouTube Channel.
