Author: Dan Langevin

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

For the past 10-15 years, APIs have been considered the “modern” way for two software systems to interact. But an API isn’t the solution to every problem.

At Vericred, we provide large volumes of health and benefit data to partners for integration into their platform or their product, and when we were developing our integration points, we were faced with a decision: do we go API-only or do we support other methods of data transfer?  Ultimately, we landed on a hybrid approach where we provide product feature-level access to our data via API, and platform integration via a set of flat files.  This approach has proved to be flexible for us, and has allowed us to develop deep integrations with minimal friction and start-up costs for our customers while minimizing bloat within our codebase.

Is this the right approach for you? Below I offer four considerations to keep in mind when deciding how you’ll integrate your data.

1. Usage of the Data (Platform vs. Product Feature)

Is the data going to be used to build a product feature or to power a platform?  This speaks to the flexibility that our customers will need when using the data.  For example, our provider-network search data answers a few simple but commonly asked questions.  The primary questions is “is Dr. X in-network for this plan?”  This lends itself nicely to an API endpoint (and, in fact, we only offer this data via API).  We would consider this a product feature: it solves a very specific need. While it’s an important part of the user experience, its functionality doesn’t bleed over into too many other user journeys in our customers’ apps.

Conversely, for many customers, our health plan data is core to their platform.  It’s displayed in multiple user journeys throughout their apps. This lends itself well to a bulk data transfer process.  Our customers would rather have this data in their own database.

2. Volume and Frequency of Update

How frequently is this data updated?  The cost, in terms of development and operations time, of pulling a large data set into their database is considerable for our customers.  If the data set is updated extremely frequently (and if the number of updates is very large), these issues are magnified.

In the previous example, our provider-network data has hundreds of millions of records and changes very frequently.  We see churn as high as 8% per month in certain networks.  The volume of the dataset is an indicator that a flat file might not be an optimal solution.

Conversely, plan data is updated once a year and rate data is updated once per year in the individual market and once per quarter in the small group market.  While in practice the data changes quite a bit more than that due to corrections, new data becoming available, and other factors, the volume and frequency of updates are far lower than provider-network data.  This makes it a candidate for the flat file approach.

3. Relationships Between Entities in the Data

One of the key design principles of a REST API is that it is entity-based.  While this has the advantage of a predictable location for each entity (e.g., Plan 123 always lives at /plans/123), it has the disadvantage of making it a bit more difficult to string together many related entities.

In the above example, if Plan 123 happens to cost $X in zip code 12345 and $Y in zip code 23456, and it also happens to be available in 12345 and 23456, but not in 34567, the customer would need to make additional API requests to determine all of that information.  When the object graph is fairly large and the customer needs to access the entire object graph to persist it to their database, flat files tend to be a better choice than API-only.

4. Format Requirements

Many of Vericred’s customers have vastly different schemata, and in order to reduce friction and increase adoption of our data platform, we made the decision to offer customized formats to those customers.  An API is, ideally, a single consistent representation of a set of resources.  Maintaining multiple formats or schemata in a single API is complex, and will often accrue technical debt within a codebase.

We made the decision to push this complexity out of the API and further down the chain.  The “standard” set of flat files we offer is generated from our API directly, but any customizations are post-processes that operate on our standard set of files.  This allows us to build out features in our core API while still meeting the needs of customers who have specific format requirements.

As a data services company, we’ve learned through working with customers over the course of the past 2 ½ years that there isn’t a one-size-fits-all solution to data transfer.  APIs are a great solution for many use-cases, but they are not the only solution.  There are several cases where transfer via flat files has proven very useful and has allowed us to separate out the general and client-specific pieces of our architecture to provide us substantial flexibility in working with our customers.

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

EpiPens are grabbing national headlines for their soaring prices.  The life-saving drug device treats anaphylaxis, a potentially fatal allergic reaction to certain foods, bee stings, medications, or latex. Amidst the rising calls for hearings and policy change, should be personal commitments to making informed decisions during the upcoming Open Enrollment Period.

Prescription Drugs and Health Plan Choices

Simply put, the prescription drugs you and your family members take should influence your choice of health plan. With over 50% of adults taking prescription drugs on a regular basis, and with these drugs accounting for more than 20% of the U.S. healthcare spend, attention should be paid to this often overlooked, but critical, element of plan selection.

Whether or not a drug is covered by a particular plan is governed by the “formulary” attached to that plan.  Formularies are lists of drugs, often found in PDF’s on carrier websites, that show whether or not a drug is covered, and at what “tier level”, along with any restrictions.  The tier level is important, as it drives what the individual will actually pay for that drug.  For example, tier 1 drugs often have a very low co-pay, perhaps $10. Meanwhile, tier 4 drugs may require the individual to pay 50% of the drug’s cost.

The price an individual pays differs, sometimes dramatically, from the wholesale and retail prices often raised in the press.  And at the end of the day, as individuals (as opposed to employers, especially self-insured employers), we care about what we actually pay out of pocket for a drug – not what occurs behind the scenes.

Formularies differ, sometimes considerably.  I have a son with peanut allergies and have bought EpiPens for years.  Last year, our health plan didn’t cover the EpiPen at all.  So we paid $600 out of pocket.  This year, the EpiPen is covered and we paid $100 for the exact same product.  This shows the significant difference between the two formularies attached to our plans this year versus  last.

The issue applies equally to seniors, especially with Medicare Advantage and Medicare Part D plans.  An article in the AARP Bulletin in November 2015 by Patricia Barry entitled “Save Money on Medicare in 2016” described the significant difference in cost a covered senior would pay for common drugs under different formularies attached to these Part D plans.  In the most extreme example, the monthly difference between the highest and lowest cost for Procrit was $535.  My personal experience was a swing of $500 a year. Imagine that on a monthly basis!

So how does one protect themselves from the shock of drugs that aren’t covered, or that are covered, but at a high out of pocket cost?

The first thing to do is check with your physician about generic alternatives as these are:

1. much more likely to be covered by a plan
2. will cost significantly less

The second thing to do is check the formularies of all available plans for the drugs you take on a regular basis.

Some health insurance shopping platforms are bringing transparency to this critical plan element through “shop by drug” functionality. This lets users enter the drugs they take to see if their drugs are covered by each available plan and, if so, at what tier level and cost.  This addresses the challenge of identifying and searching dozens of formularies.  Platforms like GetInsured.com and Take Command Health serve the individual under-65 market, while Medicare Pathfinder serves the senior (over 65) market.  Such platforms make easy work of identifying the “right” health plans based on the drugs you take and the doctors you see, all in the context of the costs and coverages of each plan.

So as we approach open enrollment, let’s use the EpiPen debate as a teaching moment to better inform ourselves and find the right plan.

The other day, I was in the car when I heard a commercial for a bariatric clinic offering lap-band surgery.  The commercial ended with these words: “…your PPO insurance should pay.”   This might lead someone to believe that their insurance would cover the entire procedure.  It.  Does.  Not.

This is by no means the only statement that may, purposely or not, mislead a consumer. The financial consequences of seeing an out-of-network provider are profound.  Absent some kind of negotiation, you’ll be responsible for the “list price” of any medical care you receive.  If your insurance plan is a PPO or a POS (a plan with out-of-network benefits), you’ll be billed for the difference between a procedure’s list price, and the amount allowed under your health plan.  That allowed amount may be a fraction of the list price, and you’re on the hook for the remainder.  This is called balance billing.  And if you have an EPO or HMO that limits you to in-network providers, you’ll be responsible for the full list price of any service rendered by an out-of-network provider.

The problem’s made worse because some healthcare providers play a little fast and loose with the terms.  A doctor who says they “accept” or “take” a plan, may simply be saying that they will bill the plan.  You’ll be responsible for any balance due.

So what do you do?  First, make sure your provider is in-network.  You can check with your insurance carrier or on your plan’s doctor search site.  But be careful. Your insurance carrier may offer many plans and many networks.  Make sure your provider participates in your particular plan.

And when speaking with a provider, you have to be very specific about asking “are you an in-network provider in my health plan.”  This leaves little room for ambiguity.  It’s also recommended that you make sure that any ancillary services are performed by in-network providers.  Your annual physical, for example, may include a blood draw, EKG and lab work – all done by different providers even though everything was taken care of in the same physical office.  So make sure those providers are also in-network.

It’s the only way to avoid having a costly out-of-network experience.