Price Transparency Regulations Could Have Empowered Patients and Revolutionized Healthcare but They’re Falling Short

A series of regulations passed over the last few years represented the most significant opportunity for the healthcare industry to solve one of its greatest shortcomings – lack of transparency.

Recently, healthcare pricing transparency has gained increasing attention as costs continue to rise to unsustainable levels, and consumers often remain in the dark, unable to make informed decisions about their medical care, or surprised by post-care bills.

In fact, healthcare has gotten so costly and billing so unpredictable that four in ten Americans reported delaying or skipping treatment entirely, trimming regular household expenses, or borrowing money.

But with the new federal and state requirements, it seemed like things were changing for the better.

- The Hospital Price Transparency rule was enacted in January 2021, requiring hospitals to provide clear, accessible pricing information online about the items and services they provide.

- The No Surprises Act (NSA) went into effect in January 2022 to help protect patients from unexpected medical bills, particularly when accessing emergency services or out-of-network care.

- Most recently, the Transparency in Coverage (TiC) rule was enacted and began rolling out in three phases. As of July 2022, health plans are required to disclose negotiated provider rates, as of January 2023, they must provide an online price comparison tool to help members estimate out-of-pocket expenses for 500 shoppable services, and as of January 2024, and they must provide estimates for all covered items and services.  

The intent of these rules was laid out from the start: improve price and quality transparency, empower patients with information, and lower costs by promoting competition.

Now that over two years have passed since the Hospital Price Transparency rule and almost one year into the TiC rule – we can look around and ask, is it helping?  

The answer is yes, but not nearly as much as it could be.

The reality is that price transparency regulations and mandating their compliance are complicated, and while the intent of these laws are clear, the letter of the laws haven’t exactly delivered.

Inconsistent or incomplete pricing data

One of the major issues we are seeing is that pricing data shared by healthcare providers is disorganized, inconsistent, and confusing.

With CMS guidelines lacking enough specificity and standardization for what must be reported and how it should be reported, the published data requires constant monitoring and adjustments depending on the source.

According to a recent report, many of the files uploaded have even been too large to access without a supercomputer and the data can be hard to understand. This makes it extremely challenging, if not impossible, to use the information for its intended purpose.  

Online price comparison tools are limited in scope

Then we have the online price comparison tools. As of today, there is a defined list of CPT^® codes* for 500 shoppable services and items for which members should be able to search, compare, and receive personalized cost estimates. While a good jumping-off point, there’s a long way to go to giving consumers the shoppable healthcare experience they desire.

To start, the tools can be inherently unfriendly for users if they don’t know which CPT^® codes are most likely to be billed for the service they need. For example, there can be multiple codes to choose from for a simple office visit depending on the length of the visit, if it’s a first visit, and the type of provider.

The tools are also only required to give results for the individual CPT^® code. This means that a member can search for a cost estimate on knee surgery, and while they will see pricing for the cost of the surgeon, it will not include pricing for other services likely involved - such as the anesthesia, facility costs, pre-surgery labs, supplies, and additional charges outside of the main surgeon’s fee. Members will have to search for each item to try to paint a complete picture of the out-of-pocket cost they will likely incur.

There’s also no expectation that quality metrics or provider reviews will be included in the comparison tool. When a member is trying to make an informed decision on their medical care, they may be thinking through factors outside of price, but there is no guarantee they will be included in their search. This makes the “shopping” process limited and disjointed.  

Compliance with the regulations

A big piece to the success of these regulations is whether they’re actually being adhered to.  While it may be too soon to tell on all of the rules, we know the Hospital Price Transparency rule is not seeing 100% compliance.

In addition, according to a recent report, prices in health insurance data files revealed that some major American hospitals omit prices from their required disclosures. This can indicate that some large hospitals are purposefully not posting their complete price list.

Without full commitment to sharing price data, it isn't easy to compile and present pricing for consumers within the tools or for consumers to access the data needed to compare prices and shop for care themselves.

It’s important to stay focused on delivering on the intent of these laws

Ultimately, while the current state of these regulations is not propelling the industry forward as quickly as many Americans would like, there are many reasons to keep pushing on and working to deliver on the ultimate intent of these laws.

Empowering consumers with transparency in pricing brings benefits to more than just consumers

Payors can achieve higher member satisfaction and retention by helping members navigate their care needs and giving them all the necessary pricing information. Plus, with a better understanding of the costs of their care, members can choose lower-cost options, such as generic drugs or in-network providers. They can also be less likely to delay care, which can help reduce claim costs and administrative expenses. Additionally, by complying with regulations, payors can avoid fines or penalties and improve their reputation with regulators and consumers.

Providers also have an opportunity to enhance patient satisfaction and loyalty through transparency in pricing. Patients who better understand their cost of care are more likely to feel in control of their experience, leading to increased trust. This can create better retention rates, higher rates of collection on payments, and more referrals, which can help grow both a provider’s patient base and revenue. Additionally, by reducing the time and resources spent negotiating with payors and patients, providers can streamline their administrative processes and focus on providing high-quality care.

Plus, while individual consumers are slower to adopt price comparison tools, there are opportunities for providers and employers to use the available information to negotiate plans, contracts, and pricing – which can lead to additional competition and savings.

So, what needs to be done?

With massive cost data files that can be incomplete and difficult to unravel coupled with a consumer-facing tool that may be limited in ability, where do things go from here to get us to real consumer empowerment and lower prices?

First, CMS is exploring several areas in its continued efforts to ensure that hospitals fully comply with the price transparency requirements, including how to further drive standardized reporting. The implementation of additional guidelines should help make prices easier to access and use for price comparisons.

Second, a lot can be enhanced with price transparency comparison tools. To truly help a member make decisions, they must understand all the services they are likely to receive and their collective pricing. This means showing prices for events of care or entire procedures instead of individual components. It would also be helpful to combine pricing data with data on quality, provider reviews, or health outcomes, so members can easily shop based on more than just price and location. Incorporating member education within the tool should also be prioritized. By helping members best understand their options and how to navigate their care decisions, you ensure they are good stewards of their health.

The bottom line is that as healthcare costs continue to rise (along with the portion that is out-of-pocket for the patient),  and the demand for a consumer-experience in healthcare grows, the need for price transparency becomes more apparent. The initiatives implemented by the government still leave a lot of room for improvement, but organizations don't have to wait for changes to the regulations to better empower consumers and provide the best price transparency experience.

At Opyn, we’ve got a team of data experts and developers that have solved how to consume the enormous and complex machine-readable files while also sourcing information from a variety of trusted areas to pull in the most complete and usable pool of pricing data. This has allowed us to work around today’s data challenges to give members the most complete estimates of care possible within our price transparency tool, Opyn Iris. With Opyn Iris, we’re also continuously planning and releasing enhancements that improve members’ experience. Whether through education, focusing on price precision, or building beyond the initial “shoppable” list of CPT^® codes, we're working to deliver on the true intent of the laws and not just what is required to comply.

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‍Mark Stamper is the Vice President of Commercial Products at Opyn Market^®. Having spent 20+ years in the healthcare industry, he is passionate about empowering consumers to take charge and feel good about their healthcare decisions, for the first time.

You can reach him at mstamper@myopyn.com.

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*CPT^® codes are a registered trademark of the American Medical Association that governs their use and upkeep.

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