Posted: 25 Mar. 2021 5 min. read

New and Future Transparency Rules Could Push Health Plans and Health Systems to Collaborate

By Anne Phelps, principal, and Christi Skalka, managing director, Deloitte Consulting, LLP

New and future rules aimed at improving health care price transparency could drive competition and help consumers make informed decisions about their care. The rules are also likely to encourage health plans to forge closer partnerships with their network providers.

During a March 11 keynote presentation at the America’s Health Insurance Plans’ (AHIP) National Health Policy Conference, we offered our thoughts on the Transparency in Coverage Rule, with which health plans will need to comply beginning on January 1, 2022. We also explained how that rule intersects with several others, including the Hospital Price Transparency Rule, which went into effect on January 1, 2021.

The idea of price transparency in health care has been around since the early 2000s. The goal has always been to advise patients about the true cost of services so that they can make informed decisions about their care and shop for services, typically the ones for which people have some ability to plan ahead. However, making prices transparent in health care is incredibly difficult compared to other industries. Every patient is unique and the services they need, as well as the complete package of medical services required, is often unknown prior to a health care encounter. Additionally, price alone is not a meaningful indication of value, which requires the consumer to also have a transparent understanding of quality.

Health plan execs are preparing for new rules

During our presentation, we released the results of a survey that we conducted with health plan strategy leaders. We wanted to find out what they thought about the upcoming Transparency in Coverage Rule, and how they intended to comply. On January 1, 2022, health plans will be required to publicly share machine-readable data on pricing information, such as negotiated rates with in-network providers, payments to out-of-network providers, and covered drug costs. Beginning in 2023, they will also be required to maintain online cost-comparison tools. Our survey uncovered three key themes:

  1. New technologies: The vast majority of health plan strategy leaders (76%) expressed some concerns about their ability to extract data from their legacy systems and intend to invest in new technology. This technology can help health plans perform detailed analytics to evaluate their own prices and see how they stack up against their competitors.
  2. New benefit designs: Most respondents (72%) agreed that the new rules would challenge them to develop benefit designs that meet the unique needs of their employer clients and members.
  3. New partnerships: Most health plan executives (64%) said they will work with their network hospitals and health systems to communicate pricing and quality information to members. They also said they would work with those groups to target specific patient populations around drivers of health (also known as social determinants) and other challenges to improve quality and cost outcomes.  

In addition to the Transparency in Coverage Rule, health plans will need to comply with the No Surprises Act, which also goes into effect next January. This rule, which was included in last December’s omnibus spending bill, is aimed at protecting patients from unexpected out-of-network bills. It also seeks to help patients understand their cost-sharing liability before seeking care from out-of-network providers. Complying with this rule will require health plans and providers to work together to determine out-of-network rates.

Where do consumers find cost and quality data?

Patients today spend more time shopping for health services online than they did prior to the COVID-19 pandemic, and many of them appear to be more focused on quality than price, according to Deloitte research.1 Rather than turning to a health plan or health system for cost or quality information, many consumers rely on third-party internet services like Yelp!2

While we expect technology innovators and vendors will tap into newly available price data to develop consumer-friendly tools, health systems and health plans are likely better positioned to explain the value of care. Along with price estimates, health plans and health systems could help their members and patients determine value based on price, quality, and accessibility of care. Most consumers are likely to look beyond just the price of care, just like they do for other services, according to our research. For example, some people might choose a five-star hotel over one that is far less expensive if it is available on the days they want to stay and offers the services they want. However, hospitals and health systems will need to demonstrate value if their prices are higher than those of their competitors. It is up to the plans and the providers to put that value story together and work with employers and brokers to reinforce that story.

Compliance with hospital transparency rule has been mixed

The rule that went into effect on January 1 requires hospitals and health systems to publish privately negotiated rates for 300 non-emergency “shoppable” services. The rules are part of an effort to create more competition by giving consumers pricing information that can be used for making health care decisions. Since the beginning of the year, we have been evaluating the impact the new transparency rules have had on hospitals and health systems.

Here are three major findings we have seen, so far: 

  1. Many large health systems have posted machine-readable files: Large health systems have released information about the rates they’ve negotiated with health plans, but overall compliance remains relatively low, particularly in highly competitive regions.
  2. Not all of the data being released is the same: Some health systems have released all of their data in a single file. Others appear to be more strategic about the data they are willing to display. They might exclude price data for some services, or rates negotiated with selected commercial health plans.
  3. Health systems are analyzing data: Health systems are taking a close look at data from other organizations and using it to see how they compare to other hospitals and health systems and to rate their position with commercial health plans in local and national markets.

By working together, health plans and health systems should try to simplify pricing strategies and offer patients accurate and complete estimates before services are provided. That could help to generate more competition, which is one of the intents of transparency. It also could improve the patient’s overall health care experience. Longer term, this could lead to better care coordination and improved health outcomes.

End notes:

1.  Deloitte October 2020 survey of New York City metro area health care consumers

2.  Yelp for health: Using the wisdom of crowds to find high-quality hospitals, Manhattan Institute, April 2017

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Anne Phelps

Anne Phelps

Principal

Anne is a principal at Deloitte & Touche LLP in the Life Sciences and Health Care practice based in Washington, DC. As the US Health Care Regulatory leader for Deloitte, Anne manages the Health Care Strategic Regulatory Implementation Services practice where she works with clients to navigate the complex world of health care regulatory changes and helps them set their business priorities and strategic opportunities in the midst of a dynamic environment. Anne has nearly thirty years of health care policy experience in a broad range of legislative and regulatory issues. Anne serves as a strategic business advisor to numerous health care stakeholders – including providers, payers, employers, life sciences companies, and investors. Prior to her career in professional services, Anne served in the George W. Bush Administration as a Special Assistant to the President and the Chief Health Policy Advisor to the President for the Domestic Policy Council and as the Executive Director of the 2004 Republican National Platform Committee. Earlier in her career, Anne worked on Capitol Hill in the United States Senate for Senators Nancy Kassebaum and Bill Frist, M.D. and was instrumental in the drafting and passage of HIPAA and other insurance and public health laws. She spent nearly five years at the National Institutes of Health in a variety of health policy and legislative roles due to her background in bioethics. Anne is a frequent speaker and author on health care regulatory and legislative issues. She has provided numerous presentations to corporate executives and board members, large policy forums, federal agencies, members of Congress, and congressional staff. Anne holds a Master of Arts in public policy from The George Washington University and a Bachelor of Arts in English from the University of Dayton (summa cum laude).

Christi Skalka

Christi Skalka

Managing Director

Christi Skalka is a managing director in the Life Sciences and Health Care practice at Deloitte, as well as the national Consulting leader for Deloitte’s Provider Pricing practice. She has more than 25 years of experience in both industry and consulting in the areas of large-scale operational improvement, pricing strategy and execution, and cost reduction across multiple sectors; these include health care providers, physician practices, health care products (manufacturing and distribution), life sciences, public sector, consumer products, and property and casualty insurance. This experience has enabled a unique cross-industry perspective to her work. Her current interests are increasing the access and affordability of health care through information transparency, meaningful patient experiences, and data-drive decision-making that accelerate the future of health. Christi is a graduate of University of Texas, where she earned her bachelor’s degree in mathematics and German. She went on to earn her MBA from the McCombs School of Business with a focus in operations management.