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By Pooja Babbrah, PBM Services Practice Lead, Point-of-Care Partners

January 2021– In late October, CMS issued a final price transparency rule, closing out a momentous march toward price transparency unlike anything seen before. Over the past few years, CMS and this administration has released four price transparency rules and one Executive Order related to surprise billing. The aim is to empower consumers to make well-informed decisions by providing an understanding of healthcare costs and coverage in advance. Combined, these rules are a game changer on several fronts. BUT for implementers, it’s even more so as it’s not just a massive, congressionally mandated health information technology (health IT) project. Stakeholders who shift their perspectives from “have to” to “want to,” will be rewarded with the advantages that lie within the new rulings. Providing patients with price in a meaningful way ahead of competitors could be a real market opportunity for payers and providers.

What is expected and when

If you count everything over the past few years, there are several rules around price transparency, some of which were finalized in the last several weeks. The goal of these rules is to make sure providers and payers are letting consumers know how much it will cost them for a specific service or procedure.  This will allow a consumer to “shop around” for their health care services – similar to how we compare prices on all other products and services in our lives. What’s unique about the most recent price transparency rules is that it requires payers and providers to ensure consumers are able to compare prices equally across multiple entities and multiple levels including discounted cash prices and negotiated prices.

  • Hospital Price Transparency Final Rule. Finalized at the end of 2019, this rule requires hospitals to make prices for items and services more transparent for patients by 1/1/2021, so this month! Hospitals must make public their standard charges (gross charges, discounted cash prices, and negotiated charges) in two ways: 1) as a comprehensive machine-readable file with all items and services and 2) in a display of shoppable services in a consumer-friendly format. This information allows consumers to compare prices and estimate the cost of care before receiving treatment.
  • Transparency in Coverage Final Rule. Just finalized, this rule requires group health plans and health insurance issuers to disclose cost-sharing and price information. This empowers consumers to price shop for coverage and understand what they are getting for their coverage. Starting on 1/1/2023, health plans must offer an online shopping tool that will allow consumers to see the negotiated rate between their provider and their plan, as well as a personalized estimate of their out-of-pocket cost for 500 of the most shoppable items and services. As of 1/1/2024, these shopping tools will be required to show the costs for the remaining procedures, drugs, durable medical equipment, and any other item or service they may need.

Leaning in to Step Ahead

No matter the level of acceptance, these final rules are here to stay, and it will be critical for stakeholders to grasp expectations and build implementation plans for compliance sooner rather than later. Leaning into these rules will distinguish the forward-thinking payers and providers from the others. Your organization must view the final rules as a tool for market differentiation, not as just a congressional mandate, to slingshot ahead of other industry players. Here are a couple of reasons to be on the forefront of implementation:

  • Demand for long-waited reform. For years, Americans endured healthcare costs that nearly doubled what citizens from other countries around the world paid. Patients not only paid more but were left in the dark about pricing of healthcare items and services until after receiving care. Recent transparency rules support putting critical pricing information in the hands of the consumers to empower them to make more informed, price-conscious decisions. The demand for price and coverage transparency is high. Stakeholders who act quickly will be rewarded.
  • Education leads to loyalty. If you are the one that is educating your consumer, then you are gaining credibility while simultaneously making a better consumer who will be more likely to want to stay with you. Getting information into the hands of patients is crucial because then nothing will be left to the imagination in terms of costs. You will be a trusted partner in care, not an omnipotent entity controlling all aspects of an individual’s healthcare decisions.

Conclusion

CMS price transparency rules are radically changing healthcare as we know it. Compliance dates are approaching and if stakeholders want to make a splash in the newly opened market, they must move swiftly, intentionally, and decisively before their competitors have the chance to catch up.

 

About the Author

Pooja Babbrah is a seasoned strategy and product leader focused on healthcare technology. She has spent over two decades leading and growing product strategy teams with her main focus on growing a company’s revenue through a well-defined and focused product strategy. Most recently, Pooja is serving as a practice lead for Point-of-Care Partners, a management consulting firm focused on healthcare technology and policy where she has helped to grow revenues of the company over 120% over the past few years.

Prior to joining Point-of-Care Partners, Pooja worked at DrFirst where she built and ran the company’s  Product Management team that was focused on new product innovation. There she launched the health care industry’s first certified ePrescribing platform for controlled substances, DrFirst’s EPCS Gold 2.0 and was also involved with the development and launch of the company’s HIPAA and DIRECT compliant secure clinical messaging platform.

Pooja is currently serving on the National Council for Prescription Drug Programs (NCPDP) Board of Trustees and has led the organization’s efforts on developing standards and transactions related to specialty medications. She currently serves on the Investment committee for the Arizona State University Foundation – Women and Philanthropy program and also services on the Water1st International Advisory Council.


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