Three Points to Focus Your Transparency in Coverage Efforts

The healthcare sector keeps changing. 

The pandemic has altered customer behavior for the foreseeable future—and possibly forever. They are leaning in to digital-first healthcare and expecting accuracy and real-time “ask and answer” solutions consistent with digital service experiences in other parts of their lives.

At the same time, significant federal transparency regulations, the No Surprises Act, and local variations on Right-to-Shop policies (among others) are creating a torrent of changes for health plans to address concurrently as they seek to improve customer satisfaction.

At Sapphire, we believe there are some elegant ways to solve for all of it through simple health care shopping experiences. Here are three key concepts we are discussing with plans right now:

1. Regulations overlap and may be incongruous

There are a number of regulations that have emerged or have become enforceable over the past 24 months that focus on giving health care customers control over their healthcare experience. From cost visibility to data ownership, these regulations are beginning to shift some fundamentals in healthcare. The main policies include:

  1. Interoperability allows patients to access their personal health information (PHI) and allow data to flow more freely between technology based organizations and the patient. This is intended to enable both patients and providers to be better informed about the patient to better coordinate care, reduce costs, and improve health outcomes.
  2. Hospital Price Transparency requires all U.S. hospitals to publish and regularly update clear and comprehensive pricing information online—including all discounted and payer-negotiated rates—in an easily accessible online location. This is intended to help Americans be more informed about the costs of shoppable hospital items or services before they need them.
  3. Transparency in Coverage requires non-grandfathered health plans and payers to provide real-time access to relevant pricing details, such as in-network rates, out-of-network charges, prescription drug pricing, and more. It is also intended to provide customers visibility into costs ahead of use but is likely to provide different costs than what hospitals show because it will be rooted in negotiated rates as opposed to street prices.
  4. The Cures Act Final Rule is designed to supply patients (and their providers) with free and secure access to their PHI which they should be able to easily access from apps on their mobile devices.
  5. The No Surprises Act provides relief to millions through the pandemic but also attempts to protect consumers who see out of network (“OON”) providers by capping their responsibility for cost sharing to what it would have been if they were treated by an in-network provider. As a result, consumers will be protected from surprise bills in situations where they have little or no control over who provides their care.
  6. Right-to-Shop policies give patients a financial incentive to seek lower cost and high-quality care even if they have a flat copayment or have met their deductible for the year.

And what’s even more challenging, the regulations—while well intended—may not line up. Dates and requirements in some cases are different leading to conflicts and confusion as to what to do and by when.

As we wait for technical guidance to emerge on some of the regulations, it will be critical to develop a clear view of how all these regulations align and where there are potential issues with compliance—and how to advocate for flexibility or changes as the industry works to deliver on the mandates.

2. Achieving the first date just gets you to the starting line from a customer experience perspective

Specifically, the Transparency in Coverage regulation requires health plans to be increasingly transparent about the price and quality of care. While medication is also important to cost transparency, timing for pharmacy has been delayed. 

The new policy requires non-grandfathered health plans and payers to provide real-time access to relevant pricing details—in-network rates, out-of-network charges, prescription drug pricing—to enable consumers making healthcare purchasing decisions through more available and visible cost.

The regulation identifies three key dates:

  1. January July 1, 2022: Machine readable files (MRFs) must be made publicly available  for ALL covered items and services.
  2. January 1, 2023: 500 shoppable services only available in an Internet-based self-service tool AND paper form if requested.
  3. January 1, 2024: Internet-based self-service tool and paper form for ALL covered items and services which includes disclosing liability and negotiated rate for prescription drugs.

While we work with a number of organizations focused on the first one, it is critical to not only remember the second and third requirements but to consider the relationship between the first one and the remaining two. The data required and available in the MRF may not be enough to generate the meaningful consumer-facing costs details in the member experience. Without addressing the relationship and bridge between them, the later requirements could lead to significant rework.

3. Keeping focus on the member experience will be critical

Digital health is here. With hundreds of vertical, service- or condition-specific virtual care solutions picking up steam, members now have access to treatments they have never had in delivery methods never imagined. But with all these solutions becoming increasingly available—the orchestration of those options is now a critical point focus for organizations seeking to deliver an exceptional customer experience.

We believe that delivering AI-based personalization in combination with a best-in-class member shopping journey that can enable frictionless access to the right care option is a really elegant way to manage such channel complexity. Delivering accurate and real-time cost within that same experience is even better. Doing all this with the member in mind will be vital to ensure they can truly benefit from all of these new options and details. Doing it well will bring a new level of consumer loyalty to the healthcare industry.

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At Sapphire, we think these are pretty big issues that will require strategic partnerships between health plans and their strategic technical partners. In our experience managing mandates with our clients for years, we also know how the dates can sneak up.

Learn more about how Sapphire works with health plans.

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Larry West is the Chief Data and Analytics Officer at Sapphire Digital. As a founder, Larry has seen the industry grow and change to focus on and try to make sense of increasingly complex data sets. He has worked through each iteration to deliver high value solutions for health plans, employers and end consumers.