The Future Is Now: Revolutionizing Healthcare Through Collaboration

Collaboration is key to overcoming administrative burdens and driving better outcomes in healthcare.

In this episode, Anna Taylor, AVP of Population Health and Value-Based Care at MultiCare Connected Care, and Heidi Kriz, Director of Medical Policy and Medical Management at Regence Health Plans, discuss their innovative approach to using FHIR for prior authorization and other administrative processes. Anna and Heidi highlight the importance of sharing operational workflows between payers and providers, much like other industries, to improve efficiency and patient care. Their pilot program for quality measure exchange demonstrated significant financial returns and operational efficiencies, earning enterprise buy-in for broader implementation.

Tune in and learn how curiosity, bravery, and collaboration can spark positive change in healthcare!

Closing gaps in interoperability could improve healthcare outcomes

The need for greater interoperability is escalating due to an increasingly sicker population. According to the CDC, 60% of Americans have a chronic disease, while 40% have two or more. As our nation ages, these numbers will likely increase as older individuals typically have more chronic conditions that require more—and more complex—care. Chronic disease is the leading driver of our $4.1 trillion annual healthcare spend. Effectively managing patient care, especially for those with chronic conditions, requires continuity across the care continuum and that continuity isn’t possible without closing gaps in interoperability first.

The disconnect

According to HealthIT.gov, 32% of individuals surveyed who had seen a provider in the previous 12 months experienced a gap in care due to ineffective information exchange. Nearly 20% had to bring a test result with them to a provider appointment; 14% had to wait an unreasonable period to get their results; 5% had to have a test or service redone because the data from the first test or service wasn’t available; and 5% had to provide their medical history more than once because the provider couldn’t find their existing chart. This lack of access to timely, accurate information is one of the primary reasons for gaps in care, a negative care experience, higher costs, and poorer outcomes.

Post-acute care

Consider the impact of interoperability gaps on patients recently discharged from a hospital to a post-acute care facility. The Agency for Healthcare Research and Quality (AHRQ) reports that 20% of patients discharged from a hospital experience an adverse event after just three weeks. The report finds that 40% of patients are discharged with test results still pending. The same percentage is discharged with orders for a “diagnostic workup,” but often without a way to close the loop on whether that workup occurred. This may be why 99% of providers choose a post-acute provider that offers interoperability over one that does not. This is likely driven by value-based care models that penalize readmissions and poor outcomes.

Coverage accuracy and insight

Another example of how gaps in interoperability cause gaps in care involves the accuracy of coverage information. Now that patients are responsible for a larger portion of their healthcare costs, they need price transparency. While many providers offer patient responsibility estimations, those estimations are often incorrect. One study found that 79% of providers are unable to correctly estimate a patient’s out-of-pocket costs due to inaccurate price and coverage information. When patients don’t know the ultimate cost of a service, they may be more likely to put it off or skip it altogether. For providers participating in value-based care and population health initiatives, this lack of benefits and coverage information can impact outcomes and, thus, reimbursement. It can also increase denied claims and create issues in the revenue cycle, leading to cash-flow challenges and delayed or inaccurate reimbursement.

Poor financial transparency can also impact the patient experience and patient satisfaction scores. One study found that 60% of patients would consider changing providers due to incorrect estimates or unexpected bills. When a patient overpays, it can take months to get a refund. And when patients pay less than they owe, they can be hit with a surprise bill they weren’t prepared to pay.

A different way of sharing data to reduce gaps in interoperability and gaps in care

While we’re making headway with initiatives like the Trusted Exchange Framework and Common Agreement (TEFCA) and the increasing adoption of industry standards like FHIR®, they require a great deal of work, money, and IT resources for healthcare organizations. However, a recent innovation is advancing interoperability in ways previously thought impossible. It begins with a digital ecosystem and decentralized network built on a platform and data fabric architecture.

Once payers and providers connect to the network, they can connect with any other payer or provider on the network to share information, and they can do it without building and maintaining multiple connections. Instead of having to aggregate data, it is always available and accessible in real time. Information is continuously refreshed and current, eliminating the need to question accuracy. And because the network is cloud-based and includes advanced technological components such as AI, participants benefit from greater interoperability without making huge infrastructure investments.

The network applies modern, secure infrastructure designed specifically to meet the needs of today’s healthcare businesses. Leveraging FHIR standards for data sharing, the network facilitates peer-to-peer communication directly between payers and providers without the need for third parties, thereby reducing the number of transactions needed to support operational workflows. And because the network enables permissioned and auditable data sharing without data aggregation, it gives data owners more control over their data.

A network and platform that simplifies the business of healthcare

As we start to close the gaps in interoperability, it’s the perfect time to reevaluate some of our long-standing beliefs about what’s possible within the revenue cycle. We don’t have to depend on data aggregation, numerous APIs for point-to-point connections, and third parties to conduct the business of healthcare. There’s a new way and it’s already used by some of the nation’s largest payers and providers.

Discover more about Avaneer Health, Avaneer Coverage Direct, and how it can help your organization close interoperability gaps to reduce gaps in care. Let’s simplify how healthcare operates together.

Decentralized Network: How Does It Work?

In a previous blog, we discussed a new approach to interoperability that doesn’t require data to be requested, aggregated, and validated each time it’s used or shared. Unlike a traditional network design, a decentralized network enables healthcare permissioned stakeholders to access continuously refreshed, always current data in real time, allowing them to communicate, transact, and collaborate with any other network participant.

In this blog, we discuss how a decentralized network enables more effective collaboration, drives innovation, and improves the healthcare experience.

How does a decentralized network work?

An excellent example of how a decentralized network works is the real-time claim adjudication process. This workflow includes:

A provider submits claims directly to a network payer from their home base instead of through their traditional clearinghouse pathway.
The network’s real-time adjudication (RTA) solution automatically examines each claim’s details against the payer’s RTA criteria.
If the claim is “clean” and deemed processable by the payer for RTA, the claim will be automatically directed to the payer’s designated RTA endpoint.
If the claim is not processable by the payer for RTA, it will automatically be directed to the payer’s traditional clearinghouse endpoint.

The ability for stakeholders to transact directly with each other simplifies the business of healthcare, modernizing how it operates and ultimately, lowers the cost of administering healthcare.

How do data security and immutability work on a decentralized network?

On a decentralized network, participants always have control over who can access their data and how that data can be accessed. This is made possible through services that manage and unlock access to permissioned data based on the use case.

When participants join the network, they must register their clinical or administrative data associated with members, patients, and practitioners. Each is given a person ID, a unique network identifier. When the network detects other organizations who share data for the same person ID, data-sharing authorization policies are automatically evaluated to determine if access to data is permissible. Where authorization is approved, data is shared directly and securely between network participants. The network itself does not see or store the data that is shared between participants.

The authorized transactions between network participants are trackable, auditable, and immutable. This effectively lowers issues of distrust, friction, and data hoarding between payers and providers.

How does a decentralized network improve the patient experience?

The administration of healthcare—those revenue cycle processes like coverage verification, prior authorization, and collections—are highly complex and often involve inefficient, manual, error-prone workflows that can impede a patient’s ability to receive timely care or to know how much it will cost. A decentralized network provides an entirely new way to administer those processes by:

Leveraging FHIR for standardizing data
Allowing real-time, permissioned access to accurate data for all healthcare stakeholders
Enabling processes that used to take days or weeks to be completed within seconds or minutes
Eliminating time-consuming, manual, error-prone workflows
Giving providers the information they need when and where they need it to provide high-quality patient care

Instead of continuing to add fixes on top of a broken system, healthcare needs to create a new, better system—a system built with a new kind of interoperability. Learn more here

Avaneer Health Honored with 2023 Best Places to Work Award

Elisabeth Cox, Vice President of Human Resources, Avaneer Health

I am honored to announce that Avaneer Health recently earned a place on Built In’s 2023 Best Places to Work in Chicago on the 50 Best Startups to Work for in Chicago list. The annual award is presented to companies of all sizes, from startups to large enterprises. It honors both remote-first employers as well as companies in large tech markets across the country.

Built In determines the winners of the award based on several factors, including compensation and benefits, criteria like remote and flexible work opportunities, programs for DEI (diversity, equity, and inclusion), and other people-first offerings—all elements we believe are essential to building a great team.

It’s all about the team

This award is a testament to our team members' passion, determination, and shared vision. We are fortunate that people with such exceptional skill sets and a passion for solving our industry’s biggest problems have come to join us at Avaneer Health. I hear all the time about how excited people are to be a part of such an innovative company.

Exponential growth

2022 has been a time of exponential growth for Avaneer Health, especially in our engineering team. We’ve more than quadrupled our company’s size, going from 12 employees in 2021 to 66 now. Our ability to achieve what we have is phenomenal, especially when you consider that we’re trying to do something that’s never been done before: Building a digital ecosystem that reinvents the back office of healthcare.

In the fourth quarter of 2022, Avaneer Health successfully completed a rigorous System and Organization Control (SOC 2) Type 1 examination, achieving an unqualified (clean) opinion from WithumSmith+Brown, PC (Withum).

Celebrating our achievements

One of the things we strongly believe at Avaneer Health is the need to celebrate our achievements, no matter how big or how small. We work hard but we know the importance of being intentional, staying in the moment, and really enjoying and acknowledging what we’re accomplishing. We have weekly “Fri-YAY” calls to recognize individuals who have achieved remarkable things that week. We also have monthly town hall meetings where we promote open, honest conversations. Many of our team members are remote so these calls help create authentic connections across the company and to promote a culture of collaboration and camaraderie.

Work-Life Balance

Work-life balance is another essential part of the Avaneer Health culture. It’s important to disconnect with time away, and to put our families first. That’s how we stay balanced and give our best when at work. We offer childcare benefits, family medical leave, flexible work schedules, parental leave, and a generous vacation/time off policy from day one. We also provide time off for civic engagement and have created many partnerships with nonprofits to help give back to our communities.

Because our reason for being is to fix healthcare’s administrative woes, we believe we need to set an example by offering outstanding healthcare benefits to our team members. And we do it with low or no payroll deductions for medical insurance premiums.

Making it real

This past November, our network went live, our initial clients are beginning to exchange data, and now we’re testing a client’s solution on the Avaneer Network™. It’s accomplishments like this that keep us stoked and moving forward.

We’re living in unexplored territory at Avaneer Health, creating pathways where none existed before. And it’s all due to our amazing team and their passion for taking our vision and making it real.

Why are we still talking about administrative waste?

Are we STILL talking about administrative waste in the American healthcare system? In a word, yes. Why? There are at least 760 billion “reasons” (dollars) annually. According to the JAMA, the United States wastes almost a quarter of its healthcare spending, somewhere between $760 billion and $935 billion, including an estimated $265.6 billion on administrative complexity.

The U.S. spends more on healthcare than any other country but realizes worse outcomes than most. According to a Commonwealth Fund study from 2019, despite spending 16.9 percent of our GDP on healthcare, the U.S. ranked last among 11 industrialized countries on health case system performance measures. Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom all do better when it comes to leading long, healthy, and productive lives.

We’ve all heard the adage, the best defense is a good offense. In the game of football, that means keeping the ball away from the other team to prevent them from scoring. That may be an admirable strategy on the gridiron, but it can be devastating in healthcare.

In our game of healthcare administration, it’s payers versus providers and patient data is the football. We punt the data to the other team but work hard to keep them from holding on to it for too long. The goal is control, but it’s the patient that loses. It’s time to pick a different strategy, one built on trust and centered on the good of the patient.

What is administrative complexity?

Examples of administrative complexity are many and varied, from having to fill out forms in duplicate, rekeying existing data into a system, or managing data via fax transmissions. Most often, administrative complexity is part of billing and insurance-related (BIR) processes. These processes attempt to answer questions like:

Is this patient eligible for this service?
Can we verify the exact benefits?
Does this service need prior authorization?
Is this provider credentialled?
Is this provider part of the right network?

Some estimate that nearly half of all BIR costs are for activities that are unnecessary or duplicative. Remember the football game? To further complicate things, the referees are so nervous that one of the teams is planning on cheating (upcoding) that they keep enacting new rules. This, in turn, leads to the players looking for new creative options to “win” the game.

Why does the system work so poorly?

At its most basic level, the system is broken, and all this money is being spent on workarounds that require human intervention. The multiple, often redundant, connection points increase costs, delay care, and create personal and organizational friction. Most of the organizations involved can’t communicate directly as they have their own unique data structures and no way to share the data, even if they wanted to. (And some don’t. That proprietary data is a key business asset.)

And, of course, there is the fax. You know, technology that died out everywhere else in the 1990s. Other industries have figured out how to electronically share data securely without losing control of prime business assets. The healthcare industry is still sending faxes. Why?

The answer is deceptively simple. Remove barriers to data sharing with an inclusive network. Connect each participant and gives access to permissioned, updated data.

Going back to our football analogy: Until we play like a team, we’ll never be able to claim victory over this mess that is the U.S. healthcare system.