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Health care price transparency and interoperability

How the Transparency in Coverage Rule affects health plans

As consumers gain access to pricing and claims information through the Transparency in Coverage Rule, health plans will need to compete more on price, service, and quality. We also expect to see improvements in care coordination and payment model innovation, helping to move the industry toward a more data-driven and consumer-centric Future of Health™.

A regulatory push to transform health insurance

The Transparency in Coverage Rule and the Interoperability Rules are part of a broad regulatory effort aimed at payers, providers, and health IT vendors. The regulations cover health care price transparency, interoperability, prohibitions on information-blocking, and criteria for health information exchanges. The intent is to bolster both competition and consumerism by giving individuals largely unfettered access to their own health care data and pricing information.

We anticipate that the transparency and interoperability rules will spur considerable and ongoing market disruption. But they could also create new opportunities. Stakeholders shouldn’t think of these rules as discrete point-in-time requirements, but as continuous efforts intended to transform the industry over time.

The health care price transparency requirements are intended to pull back the curtain on health care prices that providers and payers have long thought were proprietary. And while the new rules will require more work, they could encourage health plans to differentiate themselves in the marketplace by improving the way they serve members, employers, providers, and insurance brokers.

The Transparency in Coverage Rule and broader regulatory activity could create a strategic opportunity for health plans to drive customer engagement, better decision-making, and greater value. Health plan executives should reimagine their business models as they move toward a Future of Health™ that will be defined by radical interoperability and data-sharing, consumerism, and scientific breakthroughs.

Four strategic opportunities for health plans

Health plan leaders should consider strategies to help their organizations stay differentiated in their markets and use this newly available data to their advantage.

Health plans should create replicable, scalable, and efficient processes that can be used every month. They likely will also need to anticipate the direction of future requirements to ensure compliance, support strategy, minimize cost, and improve the tools they develop for customers. Furthermore, these processes should support ongoing data capture and analysis of own data, as well as data published by providers and other health plans. For instance, there could be value in understanding the relationship between the availability of price information, utilization, and referral patterns.

Externally, the interoperability and price transparency rules are creating mandates and opportunities for greater data-sharing in the industry. In response, health organizations should consider ways to incorporate this trend into their strategic plans. We expect the regulations will change the relationships between health plans and providers and between health plans and their competitors.

We believe the strategic opportunities for health plans will exist in these four areas:

  • Innovations in care delivery, payment models, and network design
  • Consumer-driven products and innovations
  • Trust and customer experience
  • Digital transformation

In our view, focusing only on the tactical requirement of achieving compliance could create an opening for competitors and new entrants to steal market share, and health plans should take a strategic approach to compliance. We see this as an opportunity for health plans to reimagine their business as they move toward the Future of Health™.

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