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Three Foreseen Payer Changes Due to Price Transparency Legislation

The final step in the CMS price transparency legislation is due January 2024 and requires that health plans ensure that their members have access to accurate cost of care tools that show total procedure costs for an episode of care.

These 3 major shifts will happen operationally due to price transparency:  

  1. The “Plan Design + Network Design = Productequation will become an even more critical player in the payer go-to-market landscape, particularly in commercial business. Networks will evolve to further emphasize those providers relationships that yield the best outcomes for the healthcare dollar in order to highlight value of the payer as the fiduciary of choice for their client’s medical spend.
  2. Self-insured employers will further customize plan designs to provide the richest benefits for providers who better steward their medical dollar. Three and Four tiers of member cost shares will be commonplace as payers aim to continue giving members choice of where to get care, but with designs that incentivize using those providers that are most cost effective for the appropriate level of care.
  3. Transparency can be a catalyst to achieve the singular common value proposition aligned with all payers: Empowering their members to gain access to and receive the best appropriate care for their medical dollar. This is an opportunity to revisit how payers curate this experience. Perhaps not on the same scale as ACA changed the payer landscape, but there will be another wave of focus on digital transformation to facilitate availability of the multiple data elements in payer operational capabilities necessary to achieve compliance with the mandate in the most timely, efficient, and accurate manner. This could mean a move towards standardized provider data management, claims data and history, pricing, and rules and calculation engines, and more investment in integrations, APIs, cloud data solutions etc., to move access of this vast amount of needed data further up front in the lifecycle.

Learn More How Payers Cost Estimator Member Tools Grow Member Satisfaction

Do you think health plan members will actually use the updated cost estimator tools?

It all depends on how useful the tool is. Compounding the member experience challenges that many payers are solving for with robust digital and omnichannel experience transformations, is the challenge that this mandate runs the risk of being treated like another mandate, rather than a catalyst for consumer driven healthcare.  To make it useful the need to have a great experience is table stakes.

However, behind the experience there needs to be a strategic investment that integrates some of the most complex datasets in healthcare in a way that accurately does what networks and plan designs are all tasked to do: Steer members to seek out providers and services that achieve the right care at the right place and cost with the best outcome. Seems easy enough right? Some of the most complex datasets that were once part of the “Middle or Back Office” now must calculate on-demand what the costs are for everything from an: echocardiogram at a stand-alone clinic versus a teaching hospital group to the months long care leading up to and after giving birth to a child. If this sounds simple, I have a nice beachfront house in Arizona to sell you.

Price transparency isn’t simple, but it should not become unnecessarily complicated. Avoid overcomplicating an already complicated objective by keeping a concise outcome-based Why-What statement front and center of every supporting initiative, feature and use case.  There is no need to make the outcomes too technical. Keep the outcome anchored to real life use cases that can be tested by any consumer of healthcare.

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Marc Mullins

Marc is an experienced healthcare payer leader with a passion for bringing design thinking and the user experience to the forefront, supporting the latest changes and trends in healthcare policy and digital transformation. His experience spans leading finance and compliance initiatives, digital transformations, product development, and market expansions in industry and consultant roles at numerous commercial, Medicare, and Medicaid payers.

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