Unlocking a World of Possibility

[1:22] The question I would ask you is, have we really gone far enough? I’m going to issue a challenge today, which is going to be very similar to the challenge that you just heard about, the opportunity to make a change and the opportunity to move faster.

So I want to ask you just a real quick question here in the group about 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?

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 anymore that accepts the CD? I’ll tell you my story about that in just a minute.

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 where and when you can expect that claim to be paid.

If you need to have a prior authorization, you should be able to get that prior authorization immediately upon ask.

[3:26] So, I’m going to challenge you today to really think about, are we ready, because I think that is the most important part that we have to get to.

So, 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] So I want to tell you a little bit about a personal story here that I have of my own journey. This is my mom. This is Darla. This was just after a major surgery that she had. She was declining rapidly.

She was seeing many doctors, most of which who were in the same health care 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 were there that were explaining her rapid decline.

They didn’t have the curiosity to go and look to see what was happening. They sort of treated her in the episode of care that she was getting at that very moment. And she was hospitalized many times, dehydration, other things.

[4:55] Well, it turns out she unfortunately suffered a never event. She had a prior surgery, rubber band left behind, started to strangle her stomach and esophagus, so food wasn’t passing through.

So, you can imagine the rapid decline you start having when you’re not getting nutrition.

We fast forward and we find a specialist who was willing to get her in to figure out what was happening. And it happened to be with a different health system. So they didn’t have access to her past records. So they asked us to help facilitate that.

[5:37] So we contacted her health system where her primary care doctor and the specialist she had been seeing up until that point was located.

They told us it would be a week before we could get those clinical records. They told us that we had to go visit their office and pick up a CD so we could take it to the other hospital system across the other side of the state.

So what did I do? I used a little bit of creativity. I used my mom’s password and I got into her personal portal. I took screenshots of the records that I could. I saved those on my computer.

I then uploaded those into the other doctor’s office so they could see her lab results. They could see her x rays and her scans and the scopes results of what she had previously.

[6:37] As a result of that, the doctor at her second health system was able to go and look at her history, was able to diagnose and take a look at her scans in a way others hadn’t before, and they recognized what was going on.

So, she had emergency surgery. And this picture up here is just post that surgery.

My challenge to you is, how do we truly get to an interoperable healthcare record? So I want to talk about what that means and what I think it takes to get us there.

[7:15] So here is the challenge I have for you. The first is to put the patient at the center. This is what interoperability is about. It’s about people like my mom. It’s about people like your family members and your friends who need healthcare. And you need people talking to each other. You need information to be shared.

You can’t get to those outcomes that we just saw in Wales without that data being interoperable and being accessible by everyone to change the patient’s experience.

Second, we have to actually work together. We need to challenge our old conceptions, and territorialism that exist in healthcare.

Whether you’re a payer like I represent, a provider who’s providing healthcare services to these patients, our loved ones, our family members, whether you are in technology and you’re trying to create all of this, or somewhere else in the healthcare ecosystem, we need to work together. We can’t each solve it on our own.

[8:41] We all play really important roles in that healthcare experience and delivery, and this is our time to do that.

The third thing we need to do is we need to unlock insights. We need to give ourselves permission to do this. Sometimes we put privacy, security as barriers. Of course, they’re protections. They’re necessary. They’re important. We need to protect people’s rights. We need to protect people’s personal information.

But we cannot make that a barrier or an excuse not to work together and not to unlock insights that feed the types of things that we saw earlier.

And then lastly, we have to think differently. We need to think about how we do this. We have to think about the future. We have to recognize our past, but we have to look forward to what that potential is in the future.

[9:39] So, I want to take you on just a moment of how we at BlueCross Blue Shield are starting to solve this. And many of you probably know, but maybe not all of you, that the Blue system is a system of 33 independent Blue Cross Blue Shield plans. I’ve dedicated my career at the association to creating that interoperability between the Blue system and taking that out to the entire industry.

As you can see here, we represent one in three Americans, about 117 million individuals. We contract with providers in every zip code in the country. Those two million providers, we have that interchange or connectivity.

However, as an industry of Blues in 33 separate companies, we need to actually create that interoperability among ourselves because a patient may carry an ID card of one Blue Cross Blue Shield company but get care in the area of another Blue Cross Blue Shield company. And so we create that interconnectivity among the Blue system.

[10:56] As a result of that, on an annual basis, just the interconnectivity, not the individual things that the local Blue plans do within their own market, we’re processing 388 billion claims on an annual basis, 3.2 billion eligibility and claim status transactions just between the Blues to help facilitate that interconnectivity.

What we have now done more recently is we’ve gone into real time clinical data exchange. And why have we done this? We’ve done this because we want to improve patient care. We want to benefit providers. We want to reduce the paper chase and the hassle that’s happening as providers are trying to get care delivered for their patients and get their claims paid and make sure that their patients have access to the care that they need.

We want to turn off the fax machines. We want to redeploy those resources at the providers to be able to provide 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 need to be accessible to all who are involved in that patient’s care.

So I want to take you on a little bit of 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, 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 to streamline the prior authorization process.

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. 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 to 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 out in Oregon.

What you’re going to see here is 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 they compared it against the old standard X12 formats and what they were achieving on that, and they saw some really impressive results as a response of that.

First of all, they needed to answer the basic question, is a prior authorization required. They were able to identify that the majority of 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. As they went through that, they were able to reduce and improve the timeliness of the prior authorization results by a third. They were able to make that process significantly better for the providers. That achieved a 23% improvement in the provider effectiveness and timeliness and use of their resources.

[15:38] 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 on being able to provide a response to a prior authorization request.

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.

That would be a game changer from a patient and provider experience.

[17:27] This is what I’m passionate about. I’m happy to report my mom is doing much better.

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.

Thank you.