Unlocking a World of Possibility

[1:40] The question I would ask you is: have we really gone far enough? I'm going to issue a challenge today, which is very similar to the challenge that you just heard – about the opportunity to make a change and the opportunity to move faster.

[1:55] I want to ask you a quick question here in the group: how many of you believe we are actually ready for that change? Are we ready to achieve what we just saw with AI? Do we have the interconnected systems? Do we have the information in electronic form?

[2:09] Yes. Today, 98% of claims are processed electronically. 96% of eligibility requests are processed electronically between providers and payers here in the US.

[2:20] Is that good enough? Do we really have the interconnectivity? Are we still sending faxes or putting clinical records on CD-ROMs? How many of you even have a computer that accepts a CD? I'll tell you my story about that in just a minute.

[2:41] We have a huge opportunity here, and we need healthcare to be as easy to navigate as it is to order a pizza. You should be able to know where your healthcare is being delivered. You should be able to know where you are in that experience at any given point in time. You should know if you had a service and you have a claim – where that claim is, and when you can expect that claim to be paid.

[3:15] If you need to have a prior authorization, you should be able to get that prior authorization immediately upon asking. So, I'm going to challenge you today to really think about: are we ready? Because I think that is the most important part we have to get to. Yes, we're better. We have EMRs. There aren't file rooms like you see here on the screen. But when only about 35% of prior authorizations are happening in real time, we have not met that challenge yet, and we can't achieve everything we just heard about from an AI perspective.

[3:59] I want to tell you a little bit about a personal story of my own journey. This is my mom, Darla. This was just after a major surgery that she had. She was declining rapidly. She was seeing many doctors, most of whom were in the same healthcare system, but they weren't talking to each other. They weren't looking at what was in her electronic medical records. They weren't seeing the signals that explained her rapid decline.

[4:39] They didn't have the curiosity to look to see what was happening. They treated her in the episode of care that she was getting at that very moment. She was hospitalized many times for dehydration and other things. Unfortunately, she suffered a never event: a prior surgery that left a rubber band behind that started to strangle her stomach and esophagus, so food wasn't passing through. You can imagine the rapid decline that followed when she wasn't getting nutrition.

[5:18] We fast-forward and find a specialist willing to figure out what was happening, and it was with a different health system. They didn't have access to her past records, so they asked us to help facilitate that. We contacted her health system, where her primary care doctor and specialist had been, and they told us it would be a week before we could get those clinical records. They said we had to visit their office and pick up a CD to take to the other hospital system across the state.

[6:04] So, I used a little creativity. I used my mom's password to get into her personal portal, took screenshots of the records I could, saved them on my computer, and uploaded them to the other doctor's office. They could see her lab results, x-rays, scans, and scopes. As a result, the doctor at her second health system was able to review her history, accurately diagnose, and recognize what was going on. She had emergency surgery. This picture is just post-surgery.

[7:02] My challenge to you is: how do we truly get to an interoperable healthcare record?

[7:15] The first is to put the patient at the center. This is what interoperability is about – people like my mom, your family members, and your friends who need healthcare. You need people talking to each other and information shared. You can't achieve the outcomes we saw in Wales without data being interoperable and accessible to everyone to change the patient experience.

[7:53] Second, we have to work together. Challenge old conceptions and territorialism in healthcare. Whether you're a payer like I represent, a provider, in technology, or somewhere else in the healthcare ecosystem, we need to work together. We all play important roles.

[8:31] Third, we need to unlock insights. Sometimes privacy and security are treated as barriers. They're protections and necessary, but we cannot let them prevent collaboration and insights that feed the improvements we just saw. Lastly, we have to think differently. Recognize the past, but look forward to the potential of the future.

[9:39] At Blue Cross Blue Shield, we’re creating interoperability across 33 independent Blue plans – representing one in three Americans, about 117 million individuals. We contract with providers in every zip code in the country. Those 2 million providers have connectivity, but as an industry of 33 separate companies, we need to create interoperability among ourselves.

[10:53] A patient may carry an ID card of one Blue Cross Blue Shield company but get care in another Blue Cross Blue Shield company. We create interconnectivity among the Blue system. As a result of that interconnectivity, we’re processing 388 billion claims annually, 3.2 billion eligibility and claim status transactions, just between the Blues, to facilitate that interconnectivity.

[11:19] More recently, we’ve moved into real-time clinical data exchange — and why have we done this? We’ve done it because we want to improve patient care, benefit providers, and reduce the paper chase and the hassle they face when trying to deliver care, get claims paid, and ensure their patients have access to what they need. We want to move away from fax machines. We want to redeploy those resources at provider offices so they can focus more on patient care and less on administrative work.

[12:00] And we believe, thirdly, in the power of value-based care – and the connectivity and the data and information from the clinical records, from the medical records, from the claims and data, such as lab insights, that need to be accessible to all who are involved in that patient’s care.

[12:21] So I want to take you on a more specific story around how we’re trying to use this clinical data exchange and some of the work that’s happening in the Blue system. So I’m going to take something that’s a pain point in the industry – and that’s prior authorization.

[12:37] So prior authorization has been a challenge. We’ve heard a lot about it in the last years, weeks, and months, in particular, about some of the challenges that patients have in getting access to care. And so we have taken a commitment to reduce the scope, simplify, and streamline the prior authorization process.

[13:03] Today, about 20% of prior authorizations are approved in real time. We would like to see real-time responses flip and happen 80% of the time. Nearly half of prior authorizations today are still in those fax/phone processes. They’re happening outside the electronic process. You’re not going to get to real-time responses on prior authorizations until you have that electronic connectivity.

[13:35] So in this clinical data exchange, we’re leveraging the FHIR APIs as a way to create that interoperability and move that forward. So I want to take you into this study here from Regence Blue Cross Blue Shield of Oregon and a partnership that they did with a provider organization called Multicare Connected Care in Oregon. What you’re going to see here is that they did a Da Vinci study because they wanted to look at what they could do from an interoperability standpoint. They took those FHIR APIs and compared them against the old standard X12 formats and what they were achieving on that, and they saw some really impressive results as a result of that.

[14:24] First of all, they needed to answer the basic question: is a prior authorization required? They were able to identify that the majority of the time – in fact, 84% of the time – prior authorizations weren’t even required, but the providers didn’t necessarily know that. So being able to answer that question in real time was one of the objectives.

[14:49] So they implemented this process with Multicare, and as they went through that, they were able to reduce and improve the timeliness of the prior authorization results by a third.

[15:07] They were able to make that process significantly better for the providers. They achieved a 233% improvement in provider effectiveness, timeliness, and use of their resources. So this is one example with Regence. There are a couple of others I wanted to highlight with you. Another Blue plan was able to take their instantaneous approvals and go from 12 days on average about three years ago to less than a day in being able to provide a response to a prior authorization request.

[16:01] Yet another plan – happens to be in a location that we might be in today – achieved a 96% electronic submission rate by implementing some of this technology with one of their partners. This was about putting the patient in the middle. It was about partnership and working together. And it was also about finding a way to work differently with each other. The goal here was to get to a faster yes.

[16:35] Our vision is that prior authorizations can happen while the patient is still in the provider’s office. So imagine that the patient is sitting down with their physician and they’re reviewing their case and they’re reviewing their situation, and the provider says, “You have had enough physical therapy. I think it’s time for surgery.” And for the provider to be able to, in their electronic medical record, initiate that prior authorization request, much like they do a prescription today. And by the time the patient makes their way up to the front desk, they know that their prior authorization has been approved, and they’re able to schedule their surgery.

[17:20] That would be a game-changer from a patient and provider experience. This is what I’m passionate about. I’m happy to report my mom is doing much better.

[17:33] And again, I just really want to challenge all of you in how you think about us getting there. Again, you can’t get to the types of outcomes we just heard about in AI and changing the patient experience and really advancing healthcare in a way we’ve never seen advanced before without our ability to put the patient first, to work together, to think about the data and truly make it interoperable and connected, and to think differently. So I hope you accept this challenge today. I am personally passionate about this challenge. This is what I believe we need to do, and I believe it’s people in the room like you here today who are going to make this happen.

[18:24] Thank you.