The Price Transparency and the Interoperability Rules in Healthcare by the Centers for Medicare and Medicaid Services (CMS) are part of a broad regulatory effort aimed at regularizing payers, providers, and health IT vendors. The regulations cover price transparency, interoperability, prohibitions on information blocking, and criteria for superfluous health information exchange with the aim to make consumers and other stakeholders feel more prepared, involved, and informed about their own healthcare data and pricing information.

CMS Regulations for Interoperability & Price Transparency

The Interoperability Rules are designed to make health information easily available by deterring information blocking. This requires payers and providers to remove the industry siloes that prevent seamless patient data exchange across the care continuum. This increased interoperability will help ensure providers have access to an individual’s care history to make informed clinical decisions, which may lead to improved patient outcomes.

In continuation, the Price Transparency regulations focus on commercial health coverage focusing mainly on the hospital & payer price transparency. Under the Hospital Price Transparency Final Rule, each US hospital is required to publish a machine-readable file for 300 shoppable services starting from January 1, 2021. This information must be published online, requiring no login or personal health information (PHI) for access by the end consumers.

Finally, under the Payer Price Transparency Rule, beginning July 2022, payers must publicly share machine-readable data about their negotiated rates with in-network providers, coverage rates for out-of-network providers, and drug pricing. Once the rule goes fully into effect, payers will need to update this data at least once every month.

Fig: Timeline of regulatory activities ^[2]

The impact is likely to be profound & long-lasting

It is no denying the fact that the price transparency and interoperability rules will induce considerable disruption and transform the healthcare industry over time. And, on its way, it would also create multiple new opportunities for many new & existing players in the market.

While the new rules will require continuous efforts, they would encourage health plans to better place themselves in the market by improving the way they serve members, employers, providers, and other stakeholders. Employers and 3rd party brokers might combine the pricing information with other tools to assess the value of the health plans they sell. The information could also be used to develop employee education materials, inform provider networks, benefit design decisions, and launch new value-based payment models. For consumers, the availability of price information—combined with easy-to-use and reliable insight-based tools could help them compare the costs, quality & accessibility.

Thus, the regulations combined with high-tech competitive price intelligence tools that drive actionable data could create a strategic opportunity for insurers to drive higher customer engagement, better decision-making, and greater value-based plans. Moreover, this creates an opportunity for consumer-friendly tools to help consumers understand their out-of-pocket costs and schedule the right bundle of services as advised by the providers, so they get the care they want at the location of their choice. In addition, tools such as price schedules and healthcare cost estimators can ensure healthcare providers and patients have access to the same pricing information as they partner in navigating the system.

According to a ‘Deloitte Health Plan Price Transparency and Interoperability Survey, 2021’, 54% of the executives see these regulations as a strategic opportunity beyond just regulatory compliance. The following are the three most voted activities that these executives want to pursue in partnership with health IT vendors:

• Tech investments to support price analytics and resulting adjustments to their own rates
• Coordination with providers on communicating price and quality to members and targeting specific patient populations
• Benefit design innovations and providing comparative pricing information to members

Conclusion

To summarize, the price transparency and interoperability rules are part of a bigger regulatory push that will create internal and external disruption in member, employer, and provider relationships. This opens multiple opportunities for healthcare organizations to gain a competitive advantage using the newly available data.

With the perfect culmination of tech expertise and in-depth healthcare knowledge, Brillio has developed a competitive AI/ML-powered ‘Brillio One Health Payer Competitive Intelligence’ for payers to gain service-level intelligence through a data-driven insights dashboard. Brillio is uniquely positioned to work along with healthcare organizations globally to deliver multiple such related solutions to reimagine their business as they move towards the future of health.