The clock is ticking for health payers. January 1 is the final deadline to meet expanded price transparency requirements, extending past the initial list of 500 to all covered items and services. This will allow members to see their out of pocket cost estimates for every contracted item and service within their plan’s provider network. While difficult to achieve, transparency is a vital objective that benefits employers, providers, health plans, and members in understanding costs before receiving care.
We continue to applaud efforts by the government to create standards by which plans and providers are held accountable for allowing folks to review prices, evaluate providers, compare options, and make informed care decisions. It is true that the current rules do this in an expansive way through both the requirement to share raw pricing data as well as a member-facing website showing costs for “all” items and services. Paradoxically though, the mandate’s focus on rates force payers to publish vast amounts of data which present an incomplete – and inaccurate – picture of the actual cost of care because it doesn’t take into account the way billing and claims adjudication occurs between providers and health plans.
If plans and providers simply “check the box” to meet the mandates outlined in the rules, it won’t be enough to truly arm healthcare consumers with the information they need to make informed decisions that result in cost-effective, high-quality care and improved satisfaction.
Price transparency is only effective when it provides actionable insights and guidance tailored to a patient’s specific health situation, empowering patients to make informed care decisions and ultimately lowering healthcare costs. Focusing on a few critical strategies can ensure plan and provider collaboration to advance true – meaningful – transparency for patients and make a lasting impact on healthcare delivery.
Data alone doesn’t achieve transparency
The mandates set the framework and data requirements for transparency but consumers need more guidance for informed decision-making and comparisons. Health plans should be acting now to turn the conversation from compliance to true member engagement.
In addition to meeting the upcoming mandate, health plans should give members access to more realistic and accessible experiences. Patients need accurate data but also context and guidance — often sought during times of stress, pain, and worry — that help inform their care decisions. Understanding that they can compare prices is important, but it is more empowering when a complete provider picture is provided, including provider quality and reviews, specialties, and availability.
As a testament to the importance of accuracy, a recent industry insights survey revealed that 40% of consumers have found inaccurate provider information on their health plan’s website, and 77% say finding inaccurate provider information on their health plan’s site would impact their level of trust. Before the industry can collaboratively connect people to the right care at the right time –– payers, providers, and health plans must prove to patients that they’re a trusted resource through easily accessible, accurate, and reliable information.
Achieving transparency: 3 areas of focus
Moving past January’s deadline, as an industry, we should focus on making the available data more actionable and meaningful. Future policy guidance or legislation should center on provider and plan collaboration. When we think about what’s next, we want to ensure that after meeting these mandates, the healthcare industry continues to evolve this data into useful resources for patients, providers, plans, and other healthcare stakeholders. Some initial areas of focus should include clarifying how care is delivered, defining service bundles, and recognizing that costs are generated in collaboration between payers and providers. Here are some suggestions for how to do that:
- Focus on providing transparency around how care is delivered vs. items & services. A list of component costs is not useful for patients attempting to understand their options and make informed decisions. Healthcare is not delivered uniformly according to these lists of items and services, which do not reflect the reality of healthcare delivery and billing. Providers and plans use billing practices to capture the care delivered, but there is wide variation in how providers bill and what plans pay for. What is included in a specific visit with a provider? How does that provider bill the plan for services? What services does the plan pay for? How does billing affect a patient’s cost-sharing responsibility? Providing context for how care is delivered is vital in educating patients, providers, and plans.
- Define service bundles. By defining service bundles, the healthcare industry is creating a common language around how care should be billed. Project Clarity is a collaboration of payers, providers, and healthcare stakeholders focused on providing patients with the information needed to make informed provider and treatment decisions with an understanding of potential costs. We are building a scalable framework to help providers and payers provide upfront price estimates to patients. When providers and plans have a shared understanding and expectation, you can streamline underlying billing and authorization processes, further advancing transparency for members. For example, a knee surgery patient could learn beforehand what billing to expect for the surgery and any additional related services, like physical therapy, specific to their medical needs.
- Acknowledge that billing/cost is a collaboration between payer and provider. When providers and payers work toward a shared understanding of costs and services, they can work together to reduce costs. Providers will have the information they need to build the right service approach. Payers will know what to cover and how to contract services properly. Rationalizing the requirements on both sides of the system will allow workflow-optimized ways of understanding what will be billed and how much. Simply listing the costs of services doesn’t mirror the reality of healthcare costs or care delivery processes. Defining bundles is a first step toward more clarity in understanding those true costs, significantly improving the two industry approaches that create disparate and confusing care cost estimates today.
Accelerate and expand transparency through collaboration
By meeting the upcoming January 2024 mandate, health plans and providers have the opportunity to provide helpful healthcare transparency and guidance to patients wherever and whenever they need it.
The industry can help patients take control of their healthcare costs and plan ahead for the financial impacts. But we can’t stop at just meeting the mandates. It will require expanded collaboration between health plans and providers to go above and beyond these mandates to ensure patients are truly well-informed when making healthcare decisions.
Photo: sinemaslow, Getty Images
