Industry Voices—Are payers moving fast enough toward transparency?

Healthcare is inherently personal, and what’s right for one consumer may be a no-go for another. The decision-making process is just as personal, with considerations ranging from recovery time to cultural preferences to the doctor or hospital, but it’s often hindered by the lack of one critical piece of information: What will my healthcare service cost?

The Centers for Medicare & Medicaid Services is pushing new cost transparency mandates designed to fix that. Amid widespread consumer and employer demand for solutions that will help lower healthcare costs, the agency has proposed a set of rules that mirror for health plans its recent regulation to increase hospital price transparency.   

While many plans already offer cost transparency, this new rule changes the requirements, and health plans will need to move quickly once the rule is finalized, likely by the end of this year, to comply. With industry pushback on some components of the proposed rule, however, many health plans are taking a wait-and-see approach.

We suggest doing the opposite—health plans should be preparing now rather than waiting for the final rule to be announced.

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Here’s why: Compliance will likely end up being a heavy lift—after all, plans will need technology and processes to support the requirements. More importantly, though, consumers want and need transparency, with 78% reporting in a recent HealthSparq survey that they would like accurate information on how much they will pay out of pocket for services.

The mandate sets the framework for transparency—what a particular provider charges for a specific billable service—but people need context and guidance in order to compare options and make informed decisions. Health plans should be acting now to turn the conversation from mere compliance to how they can better serve their members. Here’s how to get started:

  • Review the rule: There’s a good chance that the proposed rule will be revised before it’s finalized. The current scope goes much farther than what hospitals were required to provide, so it’s reasonable to assume that changes still lie ahead.

With that in mind, review the rule with an eye toward the possible scenarios and begin planning in parallel. Flexibility is the name of the game—what do you need to do technically to prepare for the rule as proposed, and what are the decision points that are likely to affect how you move forward? What are your member experience goals, and how would greater transparency help you further them? Can you take a phased approach to increasing transparency?  

  • Gather stakeholders: Greater price transparency may ultimately require technology updates to slow, outdated claims systems, but compliance isn’t just a tech problem. Everyone in the organization, from IT to customer experience, member experience and more, has a stake in price transparency. Bring together a wide range of expertise to understand all of the use cases you need to support and ensure that you’re approaching price transparency as an opportunity to work cross-functionally to design and deliver future consumer experience plans today—not as a burden.
  • Plan your resources: It is possible to provide out-of-pocket costs to members today, but health plans—and the siloed teams that work within them—often aren’t aware of existing tools and abilities to access the information needed.

You may even have price transparency approaches in pockets of your organization today—perhaps one for the call center, another for providers making a referrals and another for care teams helping schedule appointments, for example—but those solutions (and the teams that use them) may not talk to each other. Make sure you understand the teams, solutions and data required to not only comply with the mandate but also better support members with the information they need to make smarter healthcare choices.  

  • Think strategically for the future: Health plans have different products and services, each with a distinct objective—some plans are designed to focus support around quality centers of excellence and others might be geared to narrow networks. When you consider your products and your goals, what’s important to you as an organization? Do any of your goals conflict?

We know enough from the proposed rule for health plans to start taking action now, but the mandate doesn’t go far enough. The real opportunity lies in thinking more strategically about how to use the data to serve members. Simply amassing a list of billing codes doesn’t go far enough to help someone make a decision.

The rule is the new floor—what will you build on top of that?

Matt Parker is vice president of product for HealthSparq.