The Trump administration finalized a health care price transparency rule Thursday that threatens to permanently shift power away from insurers in coming years — but seems to largely be viewed by consumer advocates as, a first step to decoding the black box of health care pricing.
The rule from the U.S. Health and Human Services Department requires insurers to post the rates they negotiate with providers for hundreds of shoppable, non-emergency services, as well as reveal drug rates for some groups.
“The final rules also require plans and issuers to disclose in-network provider negotiated rates, historical out-of-network allowed amounts, and drug pricing information through three machine-readable files posted on an internet website,” according to the rule.
The rule, supported by the Department of Labor as well as Treasury, would impact more than 200 million Americans who have private individual or employee-based insurance.
The requirement for the publicly available data files will take effect for plan or policy years beginning on or after January 1, 2022. Plans and issuers must make cost-sharing information available for 500 specified items and services for plan or policy years beginning on or after January 1, 2023, and must make cost-sharing information available for all items and services for plan or policy years beginning on or after January 1, 2024, according to Health and Human Services.
Larry Levitt, executive vice president for health policy at Kaiser Family Foundation, said if the rule goes into effect as planned, “it would significantly expand the kind of information patients have at their fingertips. But the onus will be on patients to use that information.”
There is broad consensus in the health industry that the rate of rising costs is unsustainable — and that something has to give — but which segment of the industry should bear the burden has been a debate for years.
Hospitals and providers say the cost of medical devices and unfair negotiations with insurers are the reason they have to charge as much as they do. Meanwhile, insurers say the rate of drug cost increases has been outpacing inflation, so that’s why costs are high. Pharmaceuticals say middlemen are to blame for their cut of the process, forcing the prices higher to account for it all.
The pandemic has amplified how dysfunctional the industry is, and as a result the appetite for change is even greater. While some insurers have already launched price transparency tools, and some third-party providers are already trying to dig through claims and estimate costs, those efforts are largely for patients.
But with more than 60% of the insured population coming from employer benefits programs, revealing the negotiated prices between providers and insurers poses a potential avenue to find ways to curb costs.
“Both patients and in many cases employer who rely on insures to negotiate on their behalf don’t have any sense of what prices are being negotiated,” said Christopher Whaley, a policy researcher at RAND Corporation.
But this has insurers claiming costs will rise instead of fall. They worry providers who see competitors or neighbors paid higher rates will demand the same or threaten to go out-of-network— thereby increasing costs for patients and insurers alike.
“What they are admitting is totally ludicrous— the idea that if consumers can see my price then I am going to raise them?” said Katy Talento, a former White House senior health policy adviser.
Meanwhile Levitt says the scenario is entirely possible, and that it “could end up backfiring and increasing prices. (Transparency) sounds great in an Economics 101 textbook, but the health industry does not work like an economics textbook.”
Levitt pointed to CEO salaries in health care, and how transparency hasn’t placed any pressure to reduce them.
Justine Handelman, senior vice president of the Office of Policy and Representation for the Blue Cross Blue Shield Association, said consumers are not going to be served well by the information because negotiated prices are not what patients pay.
“Today’s final rule will not provide consumers with the clear, easily understandable information that they are looking for. Instead, it’s likely to have the unintended consequences of confusing consumers and increasing prices – something no one wants.” Handelman said, adding that existing transparency tools for consumers are adequate to help them price shop for services like scans and tests and other non-urgent services.
But even among some shoppable services, which would help employers in self-insured plans, some say convenience over cost is the greatest driver of higher costs. For example, a doctor using one medical record platform in a health system is likely to refer a service within the same system so the results are immediately accessible. By comparison, sending a patient to shop around will result in a cheaper visit, but it would delay the time for a doctor to review results of a test, for example. If its more convenient for patient and doctor, and the visit is covered, there is less incentive to change the habit.
“We have to be cautious in assuming just because we put prices out there, it will lower the aggregate cost of health care,” said Jeff Levin-Scherz, co-leader of the Health Management practice of Willis Towers Watson.
It’s good from a policy perspective, he added, but not a guarantee. Previous research has shown that despite the existence of privacy tools, and increasing shift of the cost burden to patients, there hasn’t necessarily been a shift in consumer trends.
Regardless of if they agree with the policy’s intent, experts believe the action is a step in the right direction — and would be hard to reverse no matter who is elected on November 3.
“It will be impossible to walk backwards on this,” said HHS Sec. Alex Azar, calling the current system “shadowy.”
But KFF’s Levitt said because full implementation of the rule doesn’t apply until 2024, there is time for it to be negotiated and possibly watered down. Still, this rule, combined with the transparency mandate on hospitals, is an impactful measure that will mark President Donald Trump’s legacy, Levitt said.
“The Trump administration’s efforts around price transparency have moved the discussion forward a lot more than has ever been the case,” he said. “Greater transparency has the potential to shine a spotlight on the high prices of health care, which could unleash political, if not market, forces.”
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