Unlocking the Full Potential of Healthcare

Imagine this: A healthcare ecosystem where payers, providers, patients, and partners can seamlessly connect to securely share information directly with each other, tearing down the barriers in healthcare. Also in this ecosystem, innovators can deploy and scale solutions that improve healthcare experiences by leveraging a network, standards, and processes that are developed collaboratively and can work for all. This is the vision behind Avaneer Health.

A conversation in 2017 sparked the vision between a small group of healthcare industry leaders who saw the potential for a new way of working together. They discussed how to create an ecosystem that facilitates collaboration, real-time data sharing, distributed governance, and common processes running in a trusted, permissioned, and secure environment wherein participants can transact with one another. The conversation grew to include an impressive group of innovative leaders from both payers and providers who shared the enthusiasm and vision of creating a healthcare network to enable direct connectivity between participants. This connectivity would include common data models, the latest in technology standards and infrastructure capabilities, modern security, and immutability that could be the answer to solving healthcare’s connectivity and interoperability issues.

Those early conversations led to the launch of Avaneer Health with support its initial founding members — Anthem (now Elevance), Cleveland Clinic, CVS Aetna, HCSC, IBM Watson Health (now Merative), PNC Bank, and Sentara Healthcare in June of 2021. These organizations put aside their individual views, competitive overlap, and individual interests, and committed to work together towards a common goal of advancing healthcare transformation. Avaneer Health is focused on creating a network with common infrastructure, interoperability tools, solutions, and a solution exchange capable of enabling the transformation of healthcare. The Avaneer Health team and the founding organizations continue to work together to co-develop joint processes and solutions. This type of collaboration creates opportunities for business models yet unimagined to help solve age-old challenges and unlock massive cost, process, and technology inefficiencies.

In an industry where new, innovative solutions often bring new complexities and have trouble getting to scale, Avaneer Health is working to create an ecosystem, a platform for collaboration, and a secure industry infrastructure that can help improve efficiency, and enhance outcomes, save billions in administration costs and, most importantly, improve patient outcomes and the overall patient experience. With the platform coming to life, we are now turning our attention toward growing the ecosystem of organizations that are committed to tearing down the barriers that have plagued healthcare for decades. Please reach out if you and your organization want to be part of the next generation of healthcare.

Using Network as a Service to Finally Resolve Healthcare’s Interoperability Challenges

Lack of interoperability has been the bane of healthcare for decades. That’s not to say there hasn’t been progress. In March of 2020, HHS announced that it had finalized two rules that would give patients “unprecedented safe, secure access to their health data.” The new rules can put patients in control of their data while increasing transparency and security.

This is fantastic news for patients and long overdue. But when will providers and payers achieve the same interoperability, transparency, and access to real-time data to help reduce administrative burdens, lower costs, and improve outcomes? While initiatives such as FHIR (Fast Healthcare Interoperability Resources) are making substantial headway, there are still barriers standing in the way. Concerns about security and trust combined with interoperability and operational challenges between payers and providers continue despite immense progress.

But there is new hope that an answer may be at hand and it’s coming out of the private, non-healthcare sector.

Network as a Service

Seamlessly sharing data among multiple entities is a challenge that other industries have already solved. Zelle is a prime example. In the past, if an individual wanted to send money to another person, they had a number of options—all manual. They could wire the money through a financial institution for a fee. They could write out a check and send it through the mail. Or they could go to their bank and get a money order and send it to the recipient. Once received the recipient would have to sign the check or money order and take it to the bank, then wait. It could take days, sometimes more than a week, for the deposit to be validated and accepted. Even wired money can take three or more days to process.

Today, consumers can use Zelle. All they need to do is sign up for a Zelle account with their bank and begin transferring funds – with only a phone number or email from the recipient. With Zelle, funds move between financial institutions on a financial network with multiple parties seamlessly interacting. It all takes place through a single connection point.

It begs the question as to why a similar approach can’t be taken with healthcare data. In fact, it can. While medical clearinghouses already share claims data between providers and payers, they work in a closed, linear system. What healthcare needs is a single, secure network that acts as an intermediary and neutral party to govern access within each transaction—not just clinical transactions, but administrative transactions as well. The network needs to include:

Single, digital patient identifiers
Blockchain technology to improve collaboration and data security
Willingness of patients, providers, and payers to share information within the network

The key is blockchain technology, which can help improve collaboration and increase trust among multiple stakeholders from different enterprises. First, blockchain can enable members to access information on a single network, to help alleviate redundancy and provide consistency of records. Second, it provides secure, tamper-evident storage of transaction data and permission-based access to stored information so that the information can be protected and more reliable, and its provenance can be verifiable.

Having a centralized location for the data means payers and providers don’t have to build and maintain multiple connections and expensive APIs with each other’s systems. Fewer touchpoints mean fewer opportunities for security issues, not to mention providing reduced IT costs and resources needed to manage those gateways.

“A blockchain-powered health information exchange could unlock the true value of interoperability”

How Network as a Service Could Work for Healthcare

First, payers and providers must agree to participate and to commit data to the cloud, allowing it to be discoverable based on permissions that are set by each party. Members of the network connect via the cloud, where the ID keychain and master index match requested data to available data, locate the information and deliver it to the requestor. Certifications, cybersecurity, and compliance are all managed by an outside intermediary.

With this type of network, healthcare could vastly reduce administrative burdens like eligibility verification and prior authorizations. All information could be available in real time, reducing the time-consuming back and forth faxes, emails, and phone calls seeking information. Payers benefit by having the ability to reduce fraud and abuse. Providers benefit from fewer denied claims for administrative reasons. Both can benefit from greater efficiencies, lower costs, and improved member/patient satisfaction. Patients can benefit from a reduction in paperwork and timely access to better coordinated care.

The 2020 CAQH report suggests that the healthcare industry could save $16.3 billion, or 42 percent of existing annual spend, by transitioning to fully electronic transactions

The Bottom Line

If we think of healthcare as an orchestra, payers and providers have their own sections but must play together to create the best outcome. And patients? They’re in the audience, watching what we do next.

The bottom line is that we all need to play together well with a focus on delivery of quality care for patients. But we can’t do that without trust and transparency. With blockchain technology, we now have the ability to make this long-sought-after dream a reality. According to Deloitte, “A blockchain-powered health information exchange could unlock the true value of interoperability.” Patients are waiting- the time to act is now.

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.