This is where health insurance leadership comes together.
Becker's fourth annual spring payer issues roundtable brings
together over 400 payer and health plan executives
and more than 100 speakers to Chicago April.
This year's event includes keynote conversations with the
industry's top leaders and former president George W.
Bush. For the full agenda and event details,
visit beckershospitalreview.com
and click on the events tab in the
upper right. We're looking forward to hosting you
here in Chicago.
Hello, everyone, and welcome to the Becker's Healthcare
Podcast. I'm Scott King. Thrilled today to be
joined by Jay Nakashima, president of eHealth Exchange.
Jay, how are you doing today? Thanks so
much for joining us.
Yeah. Hey. Thank you for having me. I'm
doing great.
Excellent. Yeah. It's a new year, but, some
of the same kind of trends and topics
in health care and with health plans and
and so maybe some new ones to address.
So we'll dive into all that. But, Jay,
before we get started on the topics, I
was just wondering if you could please share
a little bit about your background and career
journey, please.
Yeah. You bet. So,
so I've been working in the health IT
space
for over thirty years.
I spent about ten years,
my first ten years with health plans
as they were merging and
acquiring others every other day,
and, was ultimately
the CIO
of an HMO
PPO.
I then moved over to the
clinical
IT space. So I worked for
a couple of large,
EHR vendors
that helped out,
hospitals and health systems.
I then went to work for a large
national
provider,
again, on the clinical IT strategy
side. And then I've been,
running
eHealth Exchange,
which is a nonprofit,
data exchange network, and I've been doing that
for the past
eight years.
Wow. Thanks for sharing your career journey, Jay.
So much great experience in there. The first
topic I wanted to get to,
how are your relationships with providers changing
as both sides face cost pressure and workforce
shortages?
Yeah. Great question.
So eHealth Exchange was created about twenty years
ago by the federal government,
as strange as that sounds,
as,
as a nonprofit
health tech company,
another strange concept.
But at any rate,
the Health Exchange was originally founded,
to help
health care providers
exchange,
rich clinical information, so patients'
electronic medical records,
and, to exchange those among healthcare providers
and with federal agencies.
So, when I mentioned federal
agencies, you might think of like the
Veterans Administration,
the largest,
healthcare provider in the country,
and the Department of Defense, who has army
hospitals, navy hospitals, etcetera. But at any rate,
hospitals,
etcetera.
But at any rate,
it really took us it really took us
a good ten years,
to get health care providers
to exchange
data
at scale and with trust.
And that was for the HIPAA treatment purposes.
And, you know, got to the point where
we were exchanging,
you know, over 20,000,000,000
healthcare
transactions
annually,
and of course, in all 50 states.
And, and now we're up to 25,000,000,000.
But the vast majority of those,
electronic medical records being exchanged
are still being exchanged for the HIPAA treatment
purpose.
So, think of
a clinician at the chair side, bedside,
tableside, whatever,
about to prescribe a medication or order a
surgery.
And we've shifted over the past five years
to also
focus on payer provider exchange,
and
provider
to public health exchange.
So, we're really excited about reducing
the burden that both payers
and providers have
when exchanging
patients' electronic
medical records.
I appreciate you shedding a light on all
that wonderful work there, Jay. A lot of
progress has been made, and certainly a lot
of growth there. Next question I want to
ask you, where do you see the biggest
gap today between payer strategy and
operational execution? I think it's, you know, in
my mind, it's really in the it's really
in the,
lack of understanding
of of how inefficient
the current processes are.
So, you know, when I speak with providers,
you know, from large sophisticated
health systems,
you know, they often tell me, oh, you
know, we don't share patient records with payers.
And just as nicely and tactfully as I
can, I say,
well, of course you do? You know, you've
been doing this for thirty, forty years.
It's just been a behind the scenes operation
that number one is required in your payer
provider
contract,
but it might be also happening in an
unscalable,
unscalable
fashion.
So, it might be happening
via,
and sorry for the non techies,
it might be using an old school HL7
version two interface,
or it might be someone swapping
Excel CSV
files,
or it might even be the dreaded fax
machine.
But regardless, that data is being exchanged today,
but it's
expensive
and clumsy,
and, and so that's what eHealth Exchange is
trying to
tackle.
We're trying to,
number one, demystify
the process,
use national standards,
and apply modern technology
so that it's easier and less expensive to
exchange
the medical records.
Are you surprised that there has to be
efforts to kinda get people to adapt to
pretty basic modern tech at this point?
Yeah.
You know, it's,
yeah, it's it's really surprising,
you know, that, that fax machines are are
not only alive and well, but they're used
at such tremendous volume currently.
And so, you know, when we speak to
payers and providers about this and we explain
the possibilities,
they really do get excited.
In terms of possibilities, what's one investment or
initiative you believe will most reshape how health
plans operate over the next two to three
years?
Yeah. Great question.
So, you know, so we we use the
national standards, which have been, you know, government
endorsed, and it's called HL seven.
And we're using,
modern
APIs. So think about
think about the the the programming
framework, you know, used in your mobile phones,
you know, for social media,
to deal with your bank,
to order coffee at Starbucks,
whatever.
And so, you know, we're leveraging that same
technology.
We're actually using the healthcare
FHIR, FHIR,
technical specifications,
to
facilitate
the movement of electronic
medical records.
And of course, we're not using mobile phones
to do this,
but we're installing
these apps,
on health plan and providers'
large
institutional
computer servers,
to facilitate the exchange
in a scalable,
standardized,
trusted
fashion.
Yeah. You know, I I know we just
kinda touched on being surprised that
people are are still using, you know, fax
machines for a lot of these records. But
I've also heard, you know, particularly at our
conferences
from payer leaders that they're surprised how many
seniors
are utilizing these apps correctly and efficiently. Have
you seen that?
I you know, I I haven't seen it
personally, but, but it's something that eHealth Exchange,
definitely
supports.
You know, I think I think I I
really haven't seen it just because our scale
is so big. Again, 25,000,000,000
records
annually.
And,
the number, the percentage of that that's facilitated
by individuals
is still relatively
small.
But, you know, to your point,
as consumers and individuals,
become more and more tech savvy,
and unfortunately,
as healthcare costs increase,
and and as patients become more vested
in their
clinical healthcare outcomes,
yeah, I see them absolutely
using
technology,
to,
for electronic medical records.
I, you know, personally
use it myself.
And, it's really helpful because, you know, like
most people, I see more than one health
care provider
in more than one setting,
and I like to have all of my
data consolidated,
in one place that I can access
via my phone or via my,
my laptop.
Absolutely.
If you could change one regulatory or industry
practice tomorrow
to improve affordability and access, what would it
be and why?
You know, there's something in HIPAA called the
minimum
necessary rule.
And, you know, this was written back, you
know, in the previous century,
before before computer systems and the Internet
were really deployed widespread.
And so what this rule is is currently
interpreted to say
is that,
HIPAA covered entities, so including payers and providers,
can only exchange
the minimum
necessary
for quality
purposes.
And so the million dollar question is, what's
the minimum necessary?
And, you know, computer systems,
be it at two in the morning or
two in the afternoon,
have a hard time interpreting that.
So I'd love,
the policy side,
to have the government
publish
an interpretation
of what is the HIPAA minimum necessary.
Yeah. I think that'd be fantastic.
I I certainly think you'll have some support
there. Yeah. The last the last thing I
want to ask you, Jay,
what issue is putting the most pressure on
health plan margins right now,
and how will you respond differently in in
2026?
Yeah. So the biggest pressure for health plan
margins right now I I mean, it's gotta
be,
you know, of course, there's,
of course, there's the medical loss ratio,
but the administrative
costs are really getting a focus in the
in,
in the media,
as well as from investors.
And, and so we're really excited to help
reduce the administrative
cost,
via electronic medical exchange.
Jay, thanks so much for joining the podcast
and for a great conversation. Look forward to
working with you again soon. Alright. Thank you,
Scott.