Healthcare

The White House Startup That’s Taking On Healthcare Payments

Though the launch of Healthcare.gov is likely a dim, distant memory for most people, at the time, it was front-page news — and not for a good reason. The site, tasked with enrolling people in the newly passed Affordable Care Act (ACA), was by all accounts poorly designed. That is putting mildly. For those interested in more colorful descriptions, it was referred to as “so bad it nearly broke the Affordable Care Act.”

It didn’t, thanks largely to the extreme efforts by a group of Silicon Valley developers that came to be called the Tech Surge, which came together and rescued the website from hordes of disorganized contractors and bureaucratic mismanagement.

The experience was unpleasant and frightening at times, but is served as a wake-up call to the federal government — and its capacity to be innovative in providing services to a world increasingly reliant on digital. When tested, its capabilities were found severely lacking, and its mainframe-based legacy systems needed full-press efforts at technological modernization.

The U.S. Digital Service (USDS) is the concrete manifestation of that effort. Launched about a year after Healthcare.gov’s initial debacle, USDS has been tasked with bringing the federal government’s technology up to speed by leveraging the skills of technology specialists. These specialists work in teams for defined tours of duty to help civil servants modernize government technological infrastructure so as to be more responsive and useful to citizens. In other words, it’s a startup that operates inside the White House, tasked with bringing government tech into the 21st century — carefully.

As an innovator working for the federal government, Executive Director of the U.S. Digital Service at the Department of Health and Human Services Misu Tasnim told Karen Webster in a recent interview that it is certainly a singular gig. While most people think “move fast and break things,” when it comes to big epoch-making innovation, that is nearly diametrically opposed to what USDS is trying to do. Some days, she noted, success is measured in how well they didn’t break anything at all.

“You can’t break things when you are tinkering with something like the healthcare system that supports 4 percent of the GDP, and serves 57 million Americans. That ethos doesn’t work,” Tasnim said. She added that the USDS method for modernizing the government’s massive, mainframe-bound legacy technology systems is to take it on in “very, very small chunks.”

It isn’t as exciting as striding on to a green field and hitting the reset button on an industry in a shot. Yet, as USDS has seen demonstrated through its recent efforts working with the Centers for Medicare & Medicaid Services (CMS) to modernize their payment and data transfer systems, the most necessary innovations aren’t always the flashiest or fastest.

“As you start to modernize these legacy systems and unlock real capabilities for patients and providers, what becomes very obvious is that working on unsexy infrastructure stuff matters, and is how we can affect the really big stuff like public health,” Tasnim said.

From Quality Payments To Upgraded Care

Early on in evaluating the USDS mandate, she told Webster, it became clear how important payments — and getting them done right, fast and cheap — is to many of the modernization efforts USDS is undertaking across federal systems.

The fact that USDS works with CMS, she noted, really drove that point home. Their first effort together — an all-hands-on-deck project with a deadline set by statute, with a payments-focused initiative — is the Quality Payment Program (QPP). The QPP is an application programming interface (API)-based approach to making it easier for healthcare providers to submit and be paid for Medicare claims.

That starting step, Tasnim told Webster, gave USDS a good look into the CMS technological landscape, and found two things. The first was a rich array of data tools with which to build the long-desired, value-based payment systems that patients, physicians and regulators have long touted as a necessary change in U.S. healthcare. The second was the fact that all that data is trapped in mainframes — the antithesis of what’s required to create a real-time, agile healthcare payments system.

“Value-based payments” is a somewhat vaguely defined concept, which means different things to different users of the phrase. Most broadly construed, Tasnim explained, value-based healthcare is built around a set of medical billing models that aren’t solely tied to payment for services rendered, but linked to recommendations that promote patient health. While more specific definitions of the concept can be debated, what became clear to USDS in building QPP was that value-based billing in the U.S. cannot and will not move forward unless CMS is on board and investing in it. That is for one primary reason: CMS is far and away the nation’s largest purchaser of healthcare services.

“What we have heard over and over is that if CMS doesn’t start investing in value-based care, no one else will want to invest in it either, because the regulation could change on a dime and they would have to shift to meet whatever future requirements CMS creates,” Tasnim said. “No one wants to make the same investment twice. So, the need to modernize the legacy IT systems is very real here — if we don’t, they won’t. The industry as a whole is waiting on us here, and it doesn’t make sense to hold [tens] of millions of people hostage on value-based care because we are handcuffed to a bunch of mainframes.”

What Unlocking Real Value-Based Care Could Look Like

When one can’t break a couple of things and see what happens, disruptive innovation in healthcare comes about by strategically laying stepping stones to bigger capability. The launch of QPP in 2018 laid the groundwork for the launch of the Blue Button product, she said, which creates an easy way for patients to access all their past claims data. That launch has supported the program’s expansion into its next launch: Data at the Point of Care, which gives healthcare providers the ability to unlock and look at all that past claims data.

The power of that, on its own, is huge, Tansim said. A provider being able to look, at a glance, at most of a patient’s past claims from its desktop can help build a better plan of care. Data at the Point of Care provides that data, and in a way that is integrated with its practice management desktop software. A separate login doesn’t work for a physician, whose focus must be on the patient in front of them, not a computer screen.

While Data at the Point of Care is a big step forward, it is also a stepping stone to better services going forward. Today, Tasnim noted, the system runs at a minimum one month behind real time. Physicians get a nearly, but not totally, complete picture. There are patients who take advantage of that window. Opiate addicts will seek several prescriptions in a short time, knowing that doctors often won’t be able to see the history within a certain blackout window. A real-time system essentially closes that window, helping everyone.

However, CMS is a big battleship, and there is an old saying about turning a battleship on a dime. The advances are possible — consumers experience real-time billing every time they swipe a card, and see a charge appear moments later. Bringing that to healthcare will take time, but the fact that this effort will be long and hard doesn’t mean it is impossible.

“We really believe there is a world coming where going to see a doctor will work much the same way in terms of [the billing interaction] people are currently having when interacting with their financial institution,” she said. “We just have about 16 million lines of COBOL to translate to get there.”

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