Mark Menton

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Another component of the government’s Transparency in Coverage mandate and No Surprises Act legislation for health insurance plans will go into effect on January 1, 2023 for price transparency. This phase of the mandate requires most commercial insurers and group payers to provide out-of-pocket cost estimates for 500 items and services to health plan members. To better understand how insurers are managing this process, we recently surveyed 200 health plan executives and the findings offered a few surprises: they overwhelmingly believe transparency is beneficial, but getting the required data is incredibly complex.

Executives Are Hopeful About Transparency

While health plan executives shared challenges with compliance, 9 out of 10 agree that price transparency is good for providers, consumers, and their own plans. The benefits of price transparency have been widely debated over the last decade and there is now widespread consensus that the opacity of pricing in healthcare is a pressing issue that must be solved. Price transparency in healthcare has been linked to the promise of consumerism – the hope that people will start to compare options and make more empowered choices versus selecting high-cost care that isn’t necessarily high quality. The mandates alone are not a silver bullet for all that ails the overly complex and expensive healthcare system, but they shed light on issues in a manner that’s never been done before.

Shedding Light on the Challenges of Transparency

When asked about the hardest aspects of keeping up with transparency mandates, executives placed data management at the top of the list. Following closely is keeping up with the CMS data schema.

The challenges plans face around data management aren’t unique to price transparency. Negotiated rates have been buried in claims adjudication systems and are used post-care delivery. It’s a major undertaking to turn that data into out-of-pocket estimates that people can easily search for and effectively use when planning their care, 

 do it at scale. Claims systems aren’t built to price care for hundreds of providers in real time. Plus, plans must apply logic to raw billing code-level rates and share them in a consumer-friendly way. They need to ensure only appropriate providers show if rates are applied to all in-network providers, and that place-of-service codes are applied properly.

Nearly all (91%) executives agree that current price transparency requirements are only as effective as the user-friendly experience they can build for consumers. The mandate itself only requires estimates to be available at the billing code level, which is 

not helpful for patients seeking information about what they will pay for care

 in a more holistic way. This means someone could search for knee surgery and may only see the professional fees for the surgeon, and not the other costs of their surgical procedure.

Nearly 3 in 5 (57%) health plan executives say they are thinking strategically to leverage the January 2023 mandate to offer new member experiences. There are a few key ways plans can help their members find, compare, and access quality care by taking the mandate and building member experiences that deliver additional value for members:

Ensure members are guided to appropriate care options that are relevant to their current health situation so they can make decisions without having to be experts.

 A person who searches for knee repair doesn’t just want the cost of the surgeon’s fees or an MRI. The best member experience will support savings opportunities for complex, end-to-end episodes of care, such as surgery, with contextual costs, details, and time involved from evaluation through recovery.

 We know from behavioral economics that people will make different choices if financially incentivized to do so. We’ve seen health plans drive people toward more cost-effective care by offering rewards as low as $25.

Even with the associated challenges with meeting the mandate, health plans are looking forward to the benefits. Nearly 4 in 5 (78%) say that new tools for price transparency will improve consumers’ experiences. Now, that’s not really a surprise. Helping improve how people experience healthcare is certainly something we can all get behind.

Mark Menton is General Manager at HealthSparq.

Articles

Another component of the government’s Transparency in Coverage mandate and No Surprises Act legislation for health insurance plans will go into effect on January 1, 2023 for price transparency.

Health Plan Executives Like Transparency Benefits, but Say Compliance is Complex

Price transparency is a primary focus for health plans in 2022 to support rising consumer demand for improved healthcare experiences and align to federal price transparency mandates. 

The mandates have the right intentions to get healthcare cost information to people, but the reality is each health plan will decide whether they simply check the box to meet the mandate or go further to provide meaningful member experience. 

Going above and beyond the mandates is where the opportunity lies for health plans to differentiate themselves and build trust with members. Below are a few ways to create a price transparency solution that people will appreciate and use.

When people are looking for healthcare, they often don’t know where to start and turn to their health plan for information. However, offering information that helps guide members to the right care, in the right place, at the right time, and for the best price is missing from the mandate. Health plans that are able to deliver their members insights and education to help them better navigate healthcare will be ahead of the curve.

: Help people plan for relevant care by making the website easy to navigate and personalized to each individual member. Are they searching for an MRI? Help them understand the differences, like MRIs with or without contrast. Anticipate the member’s needs and highlight virtual care options when appropriate – such as if they are searching for after-hours care or mental health visits. Data is powerful, use it to inform member interactions on the web and help surface helpful information to guide them.

Healthcare transparency tools are only valuable if people actually use them. Raising awareness of these tools and their value is key to fueling engagement and driving ROI as new features and functionality are rolled out.

: With price transparency impacting both hospitals and health plans - it is garnering increasing media attention.Health plans can leverage the national conversation to differentiate their capabilities and encourage more members to utilize available tools to make more informed healthcare choices.

100 executives from hospitals and health systems

 with responsibility for payer relations across the U.S. found that 92% want greater collaboration with health plans–and they want to improve the patient experience. Often online provider data is different depending on the source.

: Health plans and hospitals have the opportunity to partner to help people navigate care. By working together, pricing and provider data can become more consistent between health plan portals and health system websites, offering people confidence to make the best choices. Gaps or discrepancies in data, lead to more confusion and in some cases, people avoiding getting care at all. There is a huge opportunity to make healthcare less complex and more accessible.

Healthcare planning isn’t easy and changing behaviors to help people know they can and should research healthcare costs before obtaining care will take time. The current efforts toward price transparency are steps in the right direction and represent a huge shift in how healthcare consumers, health plans, and health systems engage with one another going forward.

Mark Menton

Articles

Health Plan Executives Like Transparency Benefits, but Say Compliance is Complex

Building Trust Through Price Transparency