Healthcare Price Transparency Price Transparency Regulations & Compliance, Policies, Programs, & Tools, Data Standards & Operational Considerations

Healthcare Price Transparency – Leaders Share Insight – Part 1

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Healthcare price transparency has a lot of attention and focus right now, especially in the mandate-driven space. But addressing price transparency via compliance with regulations is just a portion of what health plans and healthcare provider organizations should be focusing on to help make healthcare better and more cost-effective for their members and patients.

In our first Focus Area Roundtable on Costs & Transparency held April 5, 2021, a group of HCEG members working for health plans, healthcare providers, and healthcare-related technology/service organizations gathered to discuss some of the challenges, issues, and opportunities associated with addressing price transparency.

Challenges, Issues, & Opportunities Beyond Price Transparency Regulations

Andy Hoffman and Matt Parker, two thought leaders with our Focus Area Partner HealthSparq, shared a timeline overview of the Transparency in Coverage Mandate and the No Surprises Act and facilitated the following questions:

  • How are you thinking about price transparency within a rather heavily regulated space?
  • What do you see as key issues and risks in the price transparency space? What’s the role of the 80/20 rule?Healthcare Price Transparency Regulations & Compliance, Policies, Programs, & Tools, Data Standards & Operational Considerations
  • How can we really focus on what health plan members and provider patients need to make good health care decisions, knowing that members and patients often have to navigate in antagonistic payer-provider environments?
  • How can we balance supporting patient needs and operate as an ongoing business while also informing people what things are going to cost before they have to spend unlimited amounts of money?
  • What unique challenges or strategies are you thinking about with respect to price transparency? And what opportunities are you looking to take advantage of regarding price transparency?

This post shares insight and information shared by roundtable participants on the above questions pertaining to the following categories:

  1. Regulations and compliance including their importance and value to various stakeholders
  2. Price transparency policies, programs, and tools
  3. Data standards and operational considerations to advance price transparency

A second post highlighting participant responses pertaining to the following categories will be shared shortly:

  1. Increasing adoption and the importance of end-user education and support
  2. Payer-provider relationships to support access to price transparency information
  3. Advancing healthcare price transparency and next steps

RELATED: Healthcare Leaders Focus on Healthcare Policy & ACA

Thoughts on Price Transparency Regulations & Compliance

As a payer and provider, I can look at other hospitals across the state and they’re not even using our latest pricing. They’re just putting something out there to meet the requirement. So, if there’s not consistency in the data, it doesn’t actually help anybody. It just creates profound confusion. (Health Plan/Provider)

Some of the things that I hear my peers talk about is: Are we just solving certain regulatory requirements or are we solving something members think they want but won’t actually be able to use in an effective way?  Or are we on a road to something that will be of value to all the parties involved? (Health Plan)

So, what are the different things people are putting out there? How do we then know this is the best? This is what we should be doing versus this is what we are doing. Because I think everybody is just trying to meet the intent of the law or the letter of the law, but a lot of people don’t know how. And so, I think that’s one of the things that we’ve got to [consider] if there’s anything we can do. (Technology/Service Provider)

These are people who are sick and injured and hurt and need health care. And we’ve got to do our part to help them out and we can do that in a way that drives our overall business priorities. This sets the floor. We talk about these mandates being a floor and you build an experience on top of that that supports your member needs and supports your patient’s needs. (Technology/Service Provider)

So, I think it’s a good thing that the conversation has started. But I think that the end product is going to be significantly different from what it is that we’re looking at this point. (Health Plan)

I feel like the price transparency is just a way to get our prices out there – for the most part as individuals [procedures]. Unless it’s very comparative in descriptions, information is really hard to compare apples to apples between hospitals. (Provider)

Healthcare Price Transparency Policies, Programs & Tools

Whenever I used to roll out tools and or guidance, probably two decades ago and in more than one state, you have to understand the nature of what it is that your end goal is. And sort of work backward from that. But just sort of putting some things out there, you end up getting exactly what you put into it. (Health Plan/Provider)

For a lot of these hospitals, putting out their prices shows major vulnerabilities for them when it comes to inappropriate pricing, when it comes to the contracts that they’re having. It does highlight the contracts that they have with their different vendors. (Technology/Service Provider)

I think some plans are in sort of this game of chicken to some extent because the No Surprises Act isn’t finalized yet. (Technology/Service Provider)

And how can we give voice to that as part of the overall conversation with the administration because I think they’re trying but they’re sort of missing the point. So, I think it’s incumbent upon us as an industry to start to respond back on all of those fronts as to how best to rethink how to do that since it started out previously and it’s been through lots of different iterations. But that lack of standards or consistency is just…(Health Plan)

Price Transparency Data Standards & Operational Considerations

From the payer or provider perspective, without somewhat more explicit data structure guidance across the board, it’s [price transparency mandate] not helpful. (Health Plan/Provider)

We need a standardization so that everybody can follow that. (Provider)

I don’t think you can do comparisons. It’s not the latest data. It’s not even the same from hospital to hospital. It’s kind of all over the place. (Health Plan/Provider)

So as an industry, I think whether that’s vendor-specific or provider, payer, or even consumer, I think I’d like to see a conversation around how do we drive to those data standards? (Health Plan/Provider)

I would agree that the majority of people and hospitals are doing that [trying to comply in good faith.] They don’t collect the data internally in ways that’s terribly helpful. So, to publish it [price transparency information] requires an infrastructure that frankly many of them don’t have in a way that makes it useful as say maybe a payer would. (Health Plan/Provider)

Healthcare is local, that’s very much true. So that’ll impact the dynamics and the impact of what price transparency brings to the table. (Thought Leader)

There are operational challenges that we have to address and plan to address to be compliant with the new regulations that the question becomes: How will this look and feel to the consumer because pricing can vary so significantly? (Health Plan)

One of the challenges that we see when we engage with plans is: Who are the folks and entities within the organization that are trying to solve this problem? We’ve got to get fee schedules from your contracting folks, and you need member eligibility and claims verification. You had to pull all these different systems together and that’s been one of the things we’ve seen as a big challenge – especially with bigger payers, these big vast entities that have to solve these problems with groups that really hardly ever talk to each other. (Technology/Service Provider)

Join a Focus Area Roundtable – Connect with Healthcare Peers

Additional Focus Area Roundtables on Costs & Transparency – and other 2021 HCEG Top 10+ focus areas such as Healthcare Policy & ACA, Interoperability, and M & A /Joint Ventures, among others – will take place throughout 2021. If you are interested in participating, reach out to us via email or complete this short form to indicate your interests.

To receive recaps of our Focus Area Roundtables and other information of potential use for leaders of health plans, health systems, and healthcare provider organizations, join our newsletter.

Healthcare Policy ACA Focus Area Roundtable. Medicare/Medicaid beneficiaries. Health Insurance Marketplace. HealthCare Executive Group HCEG. Softheon. American Rescue Plan (ARP). Expanded APTC Eligibility and Subsidy Amounts May Drive Individual Market Growth. real-time prior authorization requirements.

Healthcare Leaders Focus on Healthcare Policy & ACA

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Early indicators of healthcare policies’ prioritization, implementation, and/or likelihood of success can provide a head start to healthcare organizations – particularly those serving Medicare/Medicaid beneficiaries and those operating in the Health Insurance Marketplace or looking to join the Marketplace in 2022. It is in that spirit that the HealthCare Executive Group (HCEG) has created Focus Area Roundtables to promote dialogue among HCEG members on important 2021 HCEG Top 10+ priorities. This post shares highlights of the initial online discussion about Healthcare Policy & ACA and presents additional information regarding future Focus Area Roundtable discussions.

See below for Additional Focus Area Roundtables Currently Being Assembled

Healthcare Leaders Discuss Healthcare Policy & ACA

On March 11th, executives from mid-sized health plans (MSH), an integrated delivery system (IDS), a national specialty care provider (NSP), and a not-for-profit consortium focused on advancing healthcare data and technology transformation (EDC) participated in the roundtable. In a roundtable fashion, these leaders shared their thoughts, ideas, and concerns on Healthcare Policy & ACA and forecasts for how the Biden administration may reshape the American healthcare ecosystem for the years to come.

The session was moderated by HCEG Executive Director Ferris Taylor and supported by Kevin Deutsch, General Manager and SVP of Health Plan Cloud at Softheon, the 2021 Focus Area Partner for Healthcare Policy & ACA.

What are your healthcare policy & ACA-related priorities, thoughts, and concerns?

Dealing with volume and uncertainty of healthcare policy and regulations amid rapidly changing and often unstructured government programs: ACA enrollment/subsidies, single payer, public option, Medicare/Medicaid buy-in, block grants, CMS Interoperability and Patient Access, etc.It was noted that no one has a crystal ball and none of the participants were “inside” of the administration, so discussions of this type help to develop the ability to respond to the many uncertainties.  The needed speed of learning and agility to respond to changes in healthcare policy is the “new normal.”  Specific perspectives were exchanged among the roundtable participants.

MSH: Expressed concern on how to keep premium costs down for members who are largely low-income.

NSP: With $2 billion at risk in value-based programs and whose patients are mostly Medicare beneficiaries with multiple comorbidities, healthcare policy needs to:

  • Facilitate cost-effective access to coverage for Medicare and other beneficiaries.
  • Establish reasonable value-based programs and not just push out a bunch of voluntary risk-sharing programs long on objectives but short on details.
  • Support coverage and payment for virtual care, particularly remote monitoring.

EDC: Shared that consortium members have noted that recently passed rules on Interoperability and Information Blocking are top of mind. These two areas of regulation and the advent of technology standards like FHIR and code sets such as LOINC, SNOMED, and others are helping to establish a common language and ‘gauge’ to help providers to speak the same language – particularly with payers.

What components of the recently passed American Rescue Plan (ARP) are most promising to you?

MSH: As a health plan, we struggle to address premium affordability and overall cost to the member and aim to keep increases to premiums at inflation or lower. Additional costs beyond the member premium often prevent members from accessing needed care. While the pandemic did not materially impact our overall member count, it did impact the composition of members as the number of commercial members decreased while Medicaid members increased.

NSP: Mentioned the need for providers and supply-side organizations to better understand the true cost of the services and products and services they provide. And another participant noted experience with a wide variety of costs and outcomes for services provided to seemingly similar patients.

FACT SHEET: American Rescue Plan and the Marketplace

What are ARP’s Immediate, Mid-Term, & Long-Term Benefits?

Healthcare Policy ACA Focus Area Roundtable. Medicare/Medicaid beneficiaries. Health Insurance Marketplace. HealthCare Executive Group HCEG. Softheon. American Rescue Plan (ARP). Expanded APTC Eligibility and Subsidy Amounts May Drive Individual Market Growth. real-time prior authorization requirements.All participants agreed there is a large and immediate benefit associated with ARP funding for vaccine-related availability, administration, and tracking.

NSP: Increased funding of COBRA premiums at 100% through September 2021 and increases to Medicaid funding seem to be a positive, as more unemployed people will be less likely to forgo or delay needed care.

Longer-term benefits from the funding and attention drawn to mental health services by the ARP were also noted. One participant called out how historically low funding and the stigma associated with mental and behavioral health services has led to a large, undiagnosed population. The need to invest more in mental health now is needed to save more serious issues later.

EDC: Consortium members have noted the importance of funding and policy related to community health centers and the need for policy and standards related to the collection and use of Social Determinants of Health (SDoH) – particularly for Dual-Eligibles.

Softheon’s Kevin Deutsch noted that changes to ACA subsidy thresholds and payment amounts brought about by the ARP will further complicate reconciliation and payment challenges. And that additional changes to subsidies and cost-sharing reductions by the Biden Administration will likely happen, further complicating these already non-trivial plan administration and payment reconciliation challenges.

RELATED: Expanded APTC Eligibility and Subsidy Amounts May Drive Individual Market Growth

Topics for Next Healthcare Policy & ACA Focus Area Roundtable

Healthcare Policy ACA Focus Area Roundtable. Medicare/Medicaid beneficiaries. Health Insurance Marketplace. HealthCare Executive Group HCEG. Softheon. American Rescue Plan (ARP). Expanded APTC Eligibility and Subsidy Amounts May Drive Individual Market Growth. real-time prior authorization requirements.As the allocated time for the roundtable flew by, Ferris moved to close the inaugural Focus Area Roundtable by asking participants what was top-of-mind in regard to Healthcare Policy & ACA and what participants thought would be the most important topics for the next roundtable. Topics raised by participants as having potential value to other HCEG members, that might be addressed in future roundtables, and would benefit from Softheon’s experience and views across their customers include:

  • Addressing policy/regulations in regard to controlling costs – particularly for high-need, high-cost members/patients.
  • Challenges, issues, and opportunities related to direct provider contracting and value-based payment arrangements.
  • Understanding and addressing costs related to internal operations and process modifications.
  • Sharing lessons learned as to what other healthcare stakeholders are doing, and not doing, in response to rapidly changing Healthcare Policy & ACA.
  • Preparing for the many regulatory deadlines (and the frequent adjustments to timelines) such as the 1/1/2022 real-time prior authorization requirements.

Additional Focus Area Roundtables Currently Being Assembled

HCEG is currently assembling roundtable discussions on Costs & Transparency and Interoperability – two other HCEG Top 10+ focus areas closely related to and impacted by Healthcare Policy & ACA.  Additional focus areas will be added in the coming months.

If you’re an executive of a health plan, health system, or healthcare provider organization who’d like to join one of these informal, small group discussions, please reach out to us here or share your contact information via this tool. And consider joining our newsletter to receive information of potential value to healthcare executives including recaps of future Focus Area Roundtables.oin HCEG and/or participate in our Focus Area Roundtables

RELATED: Healthcare Policy, ACA 2.0, Enrollment Period Lessons, & The Journey to the Exchange