Data has great potential to empower people to take control of their own health and care decisions. But this data is kept on a tight leash. Health systems and payers are each holding on tightly to their patients’ and members’ data, making it difficult to achieve consumerism’s promises of higher care quality and lower costs. We’re now sitting in between these two extremes, right at the tipping point between an unwillingness to share consumer data, and the need for more data across more hands in healthcare.
One strong force in this impending change? Government regulation. The Centers for Medicare and Medicaid Services (CMS), for instance, recently required that hospitals publish charge sheets to make costs more transparent for consumers. The administration also issued an executive order requiring plans to disclose care costs and incentivizing people to shop around for care. These necessary efforts enlist consumers to help manage rising costs. More new rules from CMS and Office of the National Coordinator (ONC) outline requirements for interoperability, health data blocking, and application program interface-based access to provider network data and patient claims data and health information.
This greater government push for data interoperability is accelerating the work industry players have been driving thus far. While these 2020 rules are focused on government plans, commercial plans expect it’s just a matter of time before regulations are applicable to everyone.
Consumer Price Transparency Isn’t New. Why Don’t More People Know It Exists?
Price transparency – even in the form of individualized out-of-pocket estimates – has been available to many health plan members for years. Although people who use these tools reportedly like them and appreciate their health plan for providing them, nearly one in two people don’t know they are available in the first place. Worthy of note? These tools are rarely available to those providers making referrals or guiding treatment plans.
Cost should be a part of the discussion people have with their providers about their overall care. While recent government rules to push hospitals to publish total cost data for consumers or negotiated rates have good intentions, they are not going to help patients shoulder the cost burden. We need to give people and their trusted providers out-of-pocket cost estimates based on a person’s unique plan benefits at point-of-care and point of referral.
New Rules, New Game Plans
These new rules help create standardized application program interfaces (using a Fast Healthcare Interoperability Resources – FHIR – format) for plans to publish their provider directories. This effort will create easy access to provider information for third-party vendors, like software developers, brokers, and even for plans to use this data in new ways to serve members.
Health plans spend tremendous time and energy creating networks that provide value to their members and balance the financial responsibilities of their own organization and external stakeholders. Sharing plan networks publicly will help members know and understand their provider options at many points along their health care journey, like provider selection, referrals, and plan enrollment options. For example, brokers could add network information to tools that help groups and prospective members make plan selection choices. Also, providers could give in-network referrals to members to support their financial and physical health needs.
Empowering Patients with Access to Personalized Data
For “consumerism” to be more than just an empty catchphrase, people must have access to complete, personalized information to make their healthcare choices. Nine in ten people consider having access to their own medical records a top priority for high quality care delivery.
New rules will make consumerism a reality. Having a well-defined playing field for claims data access will allow more health plans, providers, and app developers to be more innovative and collaborative. This effort can spur systemic improvements to help real people with real problems like surprise bills, care coordination, and more. Let the data flow!