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 Hospitalogists, Today I am so excited to bring you a fascinating op-ed from the following incredible individuals:
And it's on a topic you guys are going to be highly interested in. If you haven't heard, the state of Delaware is using Rural Health Transformation dollars to fund a $50M initiative well worth your attention - shared infrastructure, starting with prior authorization - so providers, plans, and existing systems can transact without replacing what they already run. Fun fact - Delaware appears to be the only state to explicitly target prior auth in its rural health funding application. Smart Health Network, a neutral public-benefit company, will operate the new system, working with DHIN, ChristianaCare, physician groups, and plans. Announced in July, it's in testing now. I'll let my guest writers take it from here, and thanks so much to them for surfacing this piece to me! Let’s dive in. Also, don’t forget about my virtual event on 9/30. I expect to see all of you there in ship shape. Was this email forwarded to you? Sponsored by Capacity Health Many hospital capacity problems begin as decisions or delays at the patient level, before they show up as boarding or length of stay. The clinical information needed to move care forward is fragmented across systems and buried throughout an evolving record. As new findings, results, interventions, and decisions accumulate, clinicians have to continually reconstruct the patient's clinical picture to understand what’s changed, what’s unresolved, and what’s next. Capacity Health brings that clinical context, supporting evidence, and potential next actions into one traceable view. Clinical teams see what's holding a patient back and leaders get visibility into the patient-level decisions and barriers shaping flow, boarding, disposition, and LOS. Capacity becomes something hospitals can act on patient by patient, task by task, not just measure after delays have accumulated. The state of Delaware is done with FaxesNeil Hockstein, MD · Janice Nevin, MD, MPH · Paul Meyer On a Friday in May, Dr. Neil Hockstein called an insurer to ask why prior authorization for his surgical patient had been denied. The answer was simple: the request did not include the clinical note. But the note existed. It had been in the patient’s electronic health record the entire time. The authorization request existed too. What did not exist was a reliable path between them. The denial did not reflect a judgment on the clinical facts. The reviewer had never received them. The note was not missing. The bridge was missing. Prior authorization is supposed to verify coverage and determine whether requested care meets a health plan’s clinical criteria. When the right information reaches the right place in usable form, many routine requests can be decided quickly. Instead, in an era of artificial intelligence, health care still relies on phone calls, portals and fax machines to bridge clinical systems that hold the facts and administrative systems that hold the request. Providers experience that gap as paperwork. Health plans experience it as incomplete submissions and rework. Patients experience it as waiting. Important changes are coming. Beginning in January 2027, affected Medicare Advantage plans, Medicaid and CHIP programs and plans, and certain Marketplace insurers will be required to support standards-based prior authorization APIs. Major health plans have separately pledged to expand electronic prior authorization and provide real-time responses for at least 80 percent of complete electronic approvals by 2027. These are major steps forward. But each health plan is still only one health plan. A payer can build an excellent new API and a physician’s office can still drown if every payer creates a separate connection, testing process, credentialing path and workflow. The federal rules will give health care better doorways. A market of better doorways is still not a hallway. If every plan connects separately to every provider, we risk digitizing the same N-by-N structure that produced today’s proliferation of portals, passwords, phone calls and faxes. The fax tangle becomes an API tangle. Every health plan could comply fully with the federal rule and providers could still face a different administrative path for each insurer. Compliance can succeed while relief fails. Delaware is betting on a different structure. Through its CMS-supported Rural Health Transformation Program, the state is investing in shared infrastructure that allows providers, health plans and existing health-information systems to participate in the same administrative interactions without replacing the systems they already use. Smart Health Network, which one of us leads, is working alongside the Delaware Health Information Network, health systems, physician organizations and health plans to put that model into practice. The goal is N-by-1 rather than N-by-N: each participant establishes a common connection and trust path that can be reused across counterparties. That does not mean centralizing health care. The provider keeps the clinical record and recommends the care. The health plan keeps its medical policies and makes the coverage decision. The patient is the person whose care is at stake. The shared infrastructure carries the request, authorized evidence, status and response. The network carries the evidence. The health plan makes the call. That distinction matters because shared infrastructure requires shared trust. Providers should not have to hand their records to a new central repository. Health plans should not have to surrender their clinical criteria. And neither side should have to depend on infrastructure controlled by the other. Smart Health Network is organized as a neutral public-benefit company with structural protections designed to keep the common infrastructure independent of any single payer, provider, technology company or investor. Testing began this summer with synthetic data, bringing providers, health plans, technology teams and state leaders into the same environment to work through the less glamorous questions that determine whether standards succeed in practice: identity, trust, routing, security, conformance and support. But once a connection and trust path are established, reaching another conformant participant should increasingly require configuration and participation - not another bespoke integration project. Connect once. Reach many. The economic stakes are substantial. Physicians report spending roughly 13 hours each week on prior authorization work. Smaller and rural practices feel that burden most acutely because they cannot spread it across large administrative departments. A shared path changes the economics for both sides. A provider that can reach many health plans through one common architecture avoids maintaining a separate administrative pathway for every payer. A health plan connected to more providers has a better chance of receiving complete clinical information the first time. And prior authorization is only the beginning. The same trusted infrastructure can eventually support other authorized exchanges among providers, payers, public programs and patients without requiring every organization to build another bespoke connection. Delaware first does not mean Delaware only. The standards are national. Health plans operate nationally. Providers care for patients across many payers and increasingly across state lines. The infrastructure connecting them should be capable of becoming national too. Delaware’s ambition is not to build one more local technology project. It is to prove that a different structure can work and invite others to help shape it. Between us, we have ordered care, run health systems, shaped state health policy and built infrastructure intended to connect these transactions. We know providers and health plans will not agree on every clinical determination, nor should they. But disagreement about the decision is different from failure of the machinery around it. The information needed to decide should arrive reliably. The process should be visible. And no patient should wait because the systems around their care cannot communicate. Delaware is done accepting fax as the bridge. Neil Hockstein, MD, is Delaware’s Surgeon General, Chair of the Delaware Health Care Commission, and a practicing head-and-neck surgeon. Janice E. Nevin, MD, MPH, is President and CEO of ChristianaCare. Paul Meyer is CEO of Smart Health Network, PBC. Sponsored by Regard Roughly half of specialty referrals never turn into a completed visit, and some of those patients were already diagnosed with something serious before they fell through the cracks. VBC is about to get a lot less forgiving. By 2027, prospective risk adjustment and audit-ready documentation stop being differentiators and start being table stakes. Teams still running retrospective workflows will be structurally behind. On September 30, Navina and I are breaking down what separates the orgs that will be ready from the ones that will find out the hard way in an audit. MISCELLANEOUS MADDENINGS Instant reactions from college football week 1:
This showed up on my news feed today and I couldn’t help myself. it is utterly psychotic college football behavior I just simply could not look past.  College Station is 2 hours away but instead you’re supporting your bitter rivals. Every time I’m in DKR I see some chump in a Texas A&M hat and now maybe I understand their fans’ behavior a bit better. Loyalty is dead!! (In case you couldn’t tell this is a joke and anyone is allowed to thoroughly enjoy their time inside DKR Memorial Stadium. In fact, I’ll be there on Saturday.) At long last, LIV files for bankruptcy and owes some of its top players millions of dollars. Guess that whole ‘guaranteed money’ thing didn’t play out the way we thought eh? Thanks for the read! Let me know what you thought by replying back to this email. — Blake | |||||||
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