Interoperability has long been a critical challenge for the healthcare industry, but for payers, it has become a strategic imperative. As regulatory mandates grow more stringent and the pressure to optimize quality and risk programs intensifies, healthcare payers must embrace interoperability to remain competitive.
Beyond compliance, interoperability presents opportunities to improve operational efficiency, enhance member experience, and realize better financial outcomes.
In this blog, we will explore:
- How compliance serves as the foundation for strategic interoperability.
- The challenges payers face in achieving ROI.
- The strategic priorities driving interoperability adoption in 2025.
Compliance: The Foundation for Strategic Interoperability
Regulatory compliance remains the primary driver of interoperability initiatives for healthcare payers. According to the “2024 Gartner U.S. Healthcare Payer Interoperability Benchmarks” report, which surveyed 32 U.S. healthcare payer leaders, compliance use cases were ranked three times higher than any other interoperability priority. Regulations such as the 21st Century Cures Act and the CMS Interoperability and Patient Access Final Rule (CMS-9115-F) have compelled payers to exchange clinical and administrative data seamlessly with providers and other stakeholders.
The stakes for compliance are high. Non-compliance can result in financial penalties and damage to payer reputation. Moreover, regulatory mandates have evolved to include more granular requirements, such as support for Fast Healthcare Interoperability Resources (FHIR®) standards and transparency in coverage. While these requirements are crucial for fostering a connected healthcare ecosystem, they also pose significant technical and operational challenges for payers.
Beyond Compliance: The Strategic Value of Interoperability
While compliance is the starting point, the strategic benefits of interoperability extend far beyond meeting regulatory mandates. Gartner’s research highlights that payers increasingly view interoperability as a way to:
- Enhance Quality and Risk Programs: By closing care gaps and improving data accuracy, payers can optimize risk adjustment and quality measure performance.
- Improve Member Engagement: Seamless data exchange enables personalized member experiences, from proactive health interventions to streamlined claims processes.
- Drive Cost Efficiencies: Interoperability reduces administrative redundancies and accelerates workflows, creating operational savings.
ROI Challenges: Bridging the Expectation Gap
Despite its potential, interoperability has yet to deliver consistent returns on investment (ROI) for many healthcare payers. Gartner’s survey reveals that nearly two-thirds of interoperability initiatives have not met ROI performance expectations.1 This aligns with broader industry trends, where the initial costs of technology implementation and the complexity of scaling data exchange efforts often outweigh short-term benefits.
Key Barriers to ROI
Several factors contribute to the ROI challenges of interoperability initiatives:
- Legacy Systems: Many payers operate on outdated core systems that are not natively designed for standards-based data exchange. Integrating these systems with modern platforms can be costly and time-consuming.
- Talent Shortages: Less than half of surveyed payers have HL7/FHIR® programmers on staff, relying instead on third-party vendors to fill the gap.
- Provider Resistance: Interoperability requires robust collaboration with providers, many of whom are hesitant to invest in interfaces or share data due to competing priorities.
To bridge the gap between expectations and outcomes, payers must set realistic goals and invest in scalable, long-term solutions. For example, Gartner recommends incentivizing providers to participate in data exchange by subsidizing interfaces or offering financial rewards for data-sharing compliance. Additionally, updating data usage agreements and exploring innovative prepayment reimbursement models can further align payer-provider priorities.
HealthAxis plays a crucial role in helping healthcare payers address these challenges. Our core administrative processing system (CAPS) platform is designed as a modern solution, built to seamlessly support interoperability efforts without the limitations of legacy systems. Combined with our integrated business services, HealthAxis enables payers to streamline data exchange processes, achieve scalable ROI, and foster more collaborative relationships with providers—all while maintaining compliance and improving operational efficiency.
Strategic Priorities for Interoperability in 2025
Interoperability is not a one-size-fits-all initiative. Successful payers adopt a strategic approach that aligns with their organizational goals. Based on Gartner’s findings and broader industry insights, the following priorities are shaping interoperability efforts in 2025:
1. Adopting Standards-Based Frameworks
Standards such as HL7/FHIR® have become the backbone of interoperability. In 2024, the number of payers using HL7/FHIR®-based data exchange increased significantly, reflecting the industry’s shift toward more consistent and scalable frameworks. Certified electronic health records (EHRs) and health information exchanges (HIEs) are key enablers, but payers must also ensure their own systems are equipped to handle these standards.
2. Scaling Data Exchange Capabilities
Expanding the scale of data exchange is essential for achieving meaningful ROI. This includes connecting with a broader network of providers and ensuring active submission of HL7/FHIR data. Payers should prioritize investments in technology platforms that support seamless integration and real-time data exchange.
3. Fostering Provider Collaboration
Collaboration with providers is critical for scaling interoperability. According to the Gartner report, resistant providers and funding constraints are among the top barriers to success. Payers can address these challenges by building stronger partnerships and offering value-based incentives for participation in interoperability initiatives.
4. Enhancing Data Governance
Effective data governance is the foundation of interoperability. Payers must establish clear policies for data usage, privacy, and security while ensuring compliance with regulations. Leveraging advanced analytics tools can also help extract actionable insights from shared data.
5. Integrating Interoperability with Strategic Goals
To maximize impact, interoperability initiatives should align with broader strategic objectives such as member retention, cost reduction, and competitive differentiation. For example, interoperability can support care management programs that improve health outcomes while reducing costs.
Real-World Implications and Next Steps
As the healthcare landscape evolves, interoperability will continue to play a pivotal role in driving payer success. Organizations that invest strategically in interoperability—balancing compliance with innovation—will be better positioned to meet regulatory demands, enhance member experiences, and achieve sustainable growth.
HealthAxis is committed to helping healthcare payers navigate these challenges and opportunities. With expertise in core administrative platforms and integrated business services, we offer solutions that empower payers to achieve their interoperability goals efficiently and effectively.
To learn how HealthAxis can empower your interoperability strategy, connect with our experts today.
Sources:
1. 2024 Gartner U.S. Healthcare Payer Interoperability Benchmarks
