Price transparency in healthcare has the potential to revolutionize patient care. Major changes are coming as new regulations roll out. This requires healthcare providers and eventually insurers to publish their prices so patients know what to expect.
Yet, this is no simple task, if only because of the sheer number of partners involved in each step of the process.
A recent eHI webinar sponsored by Axway explored the issues and challenges of coordinating with partners to achieve greater price transparency.
Read on to learn why representatives of eHI, Axway, and Blue Cross Blue Shield of North Dakota agree partners will need to go beyond the spreadsheet to deliver the necessary results to patients and providers.
What is the Price Transparency Rule?
Price Transparency is connected to the ongoing rollout of the CMS Interoperability Rule, aimed at empowering patients, healthcare providers, and health plans to exchange quickly data via APIs, opening up healthcare for more innovative solutions and ultimately better patient care.
Price Transparency is a simple idea that people should know how much a procedure will cost before they choose a provider. (Related is the No Surprises Act, aimed at eliminating unanticipated out-of-network bills).
As of January 1, 2021, all hospitals in the United States must make public a list of their negotiated rates for items and services — and this list needs to be online and in a machine-readable format.
Although currently delayed, the next step will be a requirement on January 1, 2023, for health insurance companies to provide an online, self-service tool for consumers to verify out-of-pocket costs.
As eHI moderator Wanneh Dixon puts it, the reality today is that Americans often make decisions about their care based on what they can afford.
She shared an example of navigating her son’s ongoing medical care and sometimes having to decide if a CAT scan is necessary or merely a follow-up that can wait to offset mounting expenses.
Empowered to make informed health care decisions, patients should be able to compare costs and better inform their care. But the rollout hasn’t been smooth: a report this summer found only 5.6% of hospitals are compliant with the price transparency rule.
What is still holding healthcare partners back and how can they make prices more transparent to better serve patients?
Navigate a complex regulatory landscape with an API-first approach
Axway VP of Healthcare, Ruby Raley, says many organizations are struggling with what feels like a confusing pile of “to-dos” that are hard to sort out and prioritize.
The key, she says, is not to look at these regulations as an administrative burden, but rather to seize the opportunity to build something new: “We could actually not just comply, but build something great,” says Raley.
She encourages decision-makers to adopt a design mindset and think about how things change over time, taking the long view for interoperability rollout.
If they plan for reuse, FHIR APIs can be set up as the building blocks of digital healthcare services. APIs allow partners to “reflect and reuse,” Raley argues.
One example Raley shares is the different provisions of the Interoperability Rule – some of which are already active (provider directory API and patient access API) and others that are still to come (payer to payer API): they can overlap if healthcare partners build their solutions on FHIR APIs.
“If you think about this from a standpoint of reuse, building one FHIR API that grabs member data or patient data could actually solve three regulatory requirements: the patient access, the provider access, and the payer to payer,” Raley explains.
She adds that shifting from a sequential, one-at-a-time view of these different regulations will allow partners much greater agility in implementing the interoperability mandates.
A classic example of API-first thinking was Jeff Bezos’ mandate that every piece of technology at Amazon had to have an API for it. Later, teams found they could do things very quickly because they already had all the hooks built in.
API-first also means thinking about how your API will be used by others. For example, with healthcare-specific FHIR APIs, the patient member data API has the same kind of data that the provider and payers need, allowing rapid reuse and less pressure on IT teams to create a new solution for each requirement.
Composable ecosystems allow for less duplication of efforts
Industry analysts Gartner and Forrester are both talking about the idea of a composable ecosystem and a low-code approach: it gives companies a set of components, they can put together to deliver services faster to their partners — whether they are internal business leaders or patients or members.
When it comes to realizing price transparency, Raley stresses that changing from a compliance mindset, with an 18-month or six-month project sprint, to a composable ecosystem of built components will help healthcare partners get to an advanced explanation of benefit or price estimator faster.
Raley concludes there is an immense opportunity to transform how healthcare works with its partners — and a more modulable healthcare company also has a major competitive advantage:
“There’s a lot of opportunity here that could help drive more informed patient decisions or could help change your portal into a competitive advantage by making you easier to do business with, and even the possibility to take advantage of some of these public prices to learn more about your competitors,” Raley said.
What’s in it for the patients and practitioners?
Dr. Anders Carlson, Medical Director of Clinical Content at telemedicine company Zipnosis shared his experience as an endocrinologist and diabetologist for over a decade. He agrees that while there is much uncertainty, there are also many opportunities built into price transparency.
He believes we’ll see three kinds of impact:
Patient choice: patients like to have the option of being seen remotely or sending an email message with a picture to a provider for interpretation and recommendations.
Giving patients the tools to see prices and know exactly what to expect means they might make different decisions about how they receive care than just doing a video visit.
Health equity: the pandemic highlighted inequalities in access to care, Carlson recalls:
“There are patients who work shifts where they can’t leave their work, or they work overnight. If they needed to come in and see me for a 15-minute visit, they had to take a full day off of their work, plus see me in the middle of what is their night. I’ve worked in clinics that aren’t on public transportation lines, where video visits would have been so much more beneficial to rural patients.”
Price transparency would help these patients see if telehealth benefits are covered — and are perhaps even more affordable — and expand their access to quality care in a real-time fashion.
Finally, Carlson believes it’s an opportunity to strengthen the patient-provider relationship. Right now, doctors advise on treatment steps without having any real idea of what it will cost or if the patient’s insurance even covers a specific type of procedure or medicine.
“When you try to come up with a plan with them, it’s hard in the current sphere to say, ‘well, here are four things that I think you might benefit from.’ I have no idea what they cost or what’s covered, or where you’re at with your deductible, or if your plan is changing in January,” says Carlson.
Cost is a huge factor in how patients make decisions, and there’s always the possibility that they’ll decline necessary treatment if they know how expensive it is from the start.
Anders says providers will likely need to lean on clinical advocates, patient advocates, and administrative staff to help coach patients through the process and make better, informed decisions.
But if price transparency is integrated into the electronic medical record in real time, providers can have a pros and cons discussion about which care option to pursue based on price as well as prognosis.
Carlson points out that it’ll be important as price transparency rolls out to really think about the interface and how it can be useful to patients and providers, how it gets integrated into the providers’ workflow in a helpful way.
Catch a replay of the Webinar here.
Next steps for insurers
Jeff Ubben, VP of Compliance, Regulatory Affairs, Special Investigations, and Chief Compliance Officer at Blue Cross Blue Shield of North Dakota, agrees that coordination between payers, providers, and patients will be critical in optimizing the objectives and the opportunities of these regulations.
Implementing and meeting compliance for price transparency regulations is a challenge for a smaller health plan like BCBS of North Dakota, with limited resources to accomplish the changes in a timely way — especially as it comes in the middle of a flurry of other healthcare-related regulations.
Some regulations hit after budgets were set for the following year, meaning it was too late to allocate new resources.
But Ubben says the company is looking at these regulations also with a strategic mindset because they have an opportunity to improve their customer experience and satisfaction.
“No one likes receiving a larger-than-expected bill or a surprise bill after receiving medical care,” says Ubben. “That type of experience is obviously not a catalyst for driving positive member experience with the health insurance company, and it’s been the leading cause of member dissatisfaction for their health plan.”
While the company is in the early stages of this work, Ubben says they’re choosing to see the regulatory compliance work as an opportunity to improve its product and enhance the services its customers receive.
A large part of this work involves robust coordination efforts. Ubben says they have made an effort recently to reach out to their provider community and enhance their relationship with them to work together to meet the challenges and opportunities presented by these regulations.
“For example, in order to provide a timely and accurate advanced explanation of benefits and customer cost expectation to our customers, say, a scheduled knee replacement surgery, it will be necessary for us to have open lines of communication with the provider so that we can know all the services the provider anticipates providing to the patient during the procedure. Our estimates of the cost associated with the procedure will only be as good as the information providers give us,” Ubben explained.
Using APIs to source data and deliver results
As for the nuts and bolts of opening up all this health data to patients, providers, and plans? Erik Holmberg, Director of IT Solution Delivery at Blue Cross Blue Shield of North Dakota, says they’re focusing on API reuse to implement these solutions faster.
“As we found with payer-to-payer, the government isn’t necessarily completely set on what they want to do or how they’re going to do it. So, we have to be prepared to pivot, and building reusable and composable architectures and technologies that support these initiatives is key for us,” said Holmberg.
He adds that he’s had to work very closely with management to put in place the appropriate technologies to support new regulatory initiatives and likens it to running a marathon: meeting deadlines while knowing there are many steps ahead to come.
Ruby Raley also points out that FHIR APIs have well-documented implementation guides and standards. So using these as a starting point to standardize data will allow healthcare partners to get up and running much faster — and it will allow different partners to trust the quality of the data they are receiving from others.
Stuck on healthcare compliance? Read our eBook, Open for innovation: Turning interoperability into opportunity.