Posted: Jul 02, 2019 4 min. read

Proposed rules on interoperability and pricing transparency are challenging, but might be exactly what patients want

By Anne Phelps, principal, US Health Care Regulatory leader, Deloitte & Touche LLP

During a recent routine medical appointment, my ear, nose & throat (ENT) specialist asked me about a lump on my thyroid—years ago, I had it biopsied in a hospital and it was quite the ordeal. With my consent, my specialist contacted my endocrinologist who shared my medical history and looped in my primary care physician. Armed with that information, my ENT specialist performed the biopsy that same day in his office. I felt an enormous sense of relief. I was able to get the procedure done right away and with far less stress than the last time. I felt taken care of by all my providers, and they each received my results electronically (all is fine, by the way!).

What is worth noting about my experience that day is these three physicians are all at different practices and have no contractual relationship with each other. However, they shared information to help me. I felt like I was in control of my health care journey. The ability to communicate with each other—and share real-time information—saved me an extra doctor visit, allowed my doctors to agree on an efficient course of action, and likely reduced costs to my health plan. This was such a positive experience that I have an even stronger sense of loyalty to my doctors because they did what was truly best for me.

Why I am telling this story? I think it helps put into context some of the thinking (as I see it) set forth by the administration’s proposed rules on interoperability and information blocking—as well as the executive order on pricing transparency that the president issued last week.1

Interoperability and pricing transparency could move us closer to true value-based care

Back in February, the administration released proposed rules to drive our health care system toward greater interoperability between electronic health records (EHRs) to improve the care quality and reduce costs (see the February 19, 2019 Health Care Current).

Here’s the rub: Care needs to be coordinated wherever patients show up—just as my physicians did for me even though they were not part of the same network. This is part of a larger effort to create a truly value-based health care system in both government and commercial programs, and to reward those that do it effectively.

The US Centers for Medicare and Medicaid Services (CMS) contends that the proposed rules will make it easier for health plans, providers, and patients to coordinate care, analyze population health trends, manage benefits, and track health outcomes and costs more effectively. The guidance would affect Medicare Advantage (MA) plans, qualified health plans sold through public insurance exchanges, Medicaid, and the Children’s Health Insurance Program (CHIP). The proposed rules, which are not yet final, have an effective date of January 1, 2020 for some programs.

Another critical component in the transition to true value-based care is the recent push toward pricing transparency. By helping consumers understand the actual cost of services, they might not be caught by surprise when bills arrive from out-of-network providers. In an executive order signed June 24, the president instructed several federal agencies to propose rules—within the next six months—to provide patients with information about hospital prices, health care resources, likely out-of-pocket (OOP) costs, and other data that could help them navigate the health care system more effectively (see the June 25, 2019 Health Care Current).

Stakeholders have concerns about new policies

I have been paying close attention to the reactions from health care stakeholders in response to CMS’s proposed interoperability rules, and to the recently released executive order. Several themes have emerged, including:

  • The implementation timeline for the proposed interoperability rules is seen as too aggressive
  • Patient data needs to be secure—whether in open-application programming interfaces or patient-facing “apps”
  • Certain information—such as competitive prices negotiated between health plans and providers—should remain proprietary

Each of these bullets represents a valid concern, and all should be considered. But it is also important that stakeholders look at the bigger picture of what is behind the new standards and why it is important. Sharing health information and data, including pricing information, can make it possible for health plans, hospitals, and clinicians to provide patients with a quality health care experience that is appropriate and affordable. Additional time may be warranted, and concerns should certainly be addressed. But I urge the health care community to view this not as just another compliance challenge, but rather as a strategic and competitive opportunity that should be embraced for the sake of patients.

This is the future of health that many consumers want. It isn’t going to be easy to get there, but in a world connected by technology (combined with our growing expectation of superior service), change is going to happen, and it is going to revolve around the consumer experience. As a patient who has experienced this type of interoperability, I know for sure I am sticking with my doctors who helped me out.

Endnotes
1. Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First, June 24, 2019

 

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Anne Phelps

Anne Phelps

Anne Phelps, Deloitte & Touche LLP, is a principal in the firm’s Life Sciences and Health Care practice and the regulatory leader of the US Health Care practice. Phelps has more than 24 years of healt