In many countries around the world, healthcare is difficult to access and certainly not guaranteed to all citizens. Global companies across multiple sectors are working to alleviate some of the red tape and confusion for consumers when it comes to the price transparency of services and procedures. In the United States, a new CMS Price Transparency rule for health insurers went into effect in January 2022, but enforcement was delayed until July 2022. This “Transparency in Coverage” regulation, along with a similar rule applying to hospitals that went into effect last year, is intended to encourage a more competitive market for medical coverage and treatment by making healthcare prices more transparent to patients before they reach the point of service.
The regulation requires group health plans and health insurance providers in the individual and group markets to publish in-network and out-of-network rates. Most group health plans, and issuers of group or individual health insurance, will be required to post their cost files online and update them at least once a month.
Avantika Sharma, a Healthcare Leader at Brillio, a digital tech company, says of the new regulation that “it is a big deal that because today people don’t know how much they would pay for a simple X-Ray or a colonoscopy until they actually access that care. With the new rule, not only individuals but even employers would get transparency into the actual costs and the contract they have entered into with the insurers.”
As of July 1st, 2022, most insurers have already started posting machine-readable files (MRFs). However, it should be noted that these huge machine files are nowhere close to being easily comprehensible for the average consumer. This obviously leaves many consumers in the dark when it comes to the real cost of their healthcare and leaves a gap to be filled by individual and group insurers. Furthermore, while insurer price transparency sees fewer compliance issues, hospitals continue to miss compliance as they see this as a burden due to the significant costs of investing in resources and software.
Due to the opacity that still exists when it comes to reading the posted files and the missed compliance on the part of hospitals, there is an opportunity for digital companies, like Brillio, to begin developing and implementing platforms for consumers to help them understand the fine print. For example, an insurer could provide cost transparency on their website or application to help consumers understand how much a procedure would cost at a hospital versus at a doctor’s office. These innovative platforms would offer the consumer flexibility to decide where and how to spend their money. While it will not be as straightforward as comparison shopping due to additional fees that might be included with a procedure or X-Ray, it will still be helpful for consumers to make more educated and practical decisions.
Sharma thinks that the CMS Price Transparency rule by itself will not be able to drive access to affordable care unless this data is properly analyzed and provided in a consumer-friendly format to drive insights and decision-making. Apart from the large scale of the files, effective implementation of the new rule also requires data cleansing and further analysis to compare rates across multiple plans, doctors, specialties, and so on.
This new rule opens exciting channels for digital technology companies to create eco-systems for providers and consumers to better share and analyze data. While there is still much work to be done, there is potential to provide greater cost visibility to the consumer, thereby moving the industry to a place where anyone can access healthcare that is both affordable and high-quality.
For more information, visit www.brillio.com.
