Price transparency, affordability and patient liability: Forging the right connection

December 22, 2020
Business Affairs

According to the Centers for Medicare and Medicaid Services (CMS), educating the consumer about cost will help drive value in healthcare.

2. The second rule follows the same logic of consumer empowerment but looks to the payers rather than to the providers.
The “Transparency in Coverage Proposed Rule” would require payers to post online their negotiated rates for in-network providers as well as their allowed amounts for out-of-network care. In the language of the rule, insurers must make available to “participants, beneficiaries and enrollees (or their authorized representative) personalized out-of-pocket cost information for all covered health care items and services through an internet-based self-service tool.”

The context
Patients have long wanted to better understand the basic cost of healthcare procedures as well as what their specific financial obligations will be. The massive shift of liability from insurers to individuals in the wake of the Affordable Care Act has sharpened this wish, as has the significant prospect of personal bankruptcy due to unexpected or unexpectedly large medical bills.

Conducting regular surveys on the patient billing experiences of insured Americans, TransUnion Healthcare has shown that patients who receive upfront, accurate cost estimates for their care are more satisfied with their overall healthcare experience. The surveys also reveal that these estimates are now expected by about half of all patients—the younger generations in particular. According to TransUnion’s Jonathan G. Wiik, Principal of Healthcare Strategy, “Allowing patients to view this information in a self-service manner helps empower them to be more engaged in their healthcare and aware of potential out-of-pocket costs.”

Avoiding unintended consequences
All of this work toward price transparency and consumer engagement is necessary if healthcare is going to fix its ballooning costs and unaffordability issues. But there is one critical piece that neither the CMS rules nor the most engaged healthcare consumer can supply. That is the responsive payment support that makes necessary medical procedures affordable.

Think about it: one possible outcome of price transparency is that the patient recognizes they simply do not have the money to go through with the procedure. Because avoided and postponed care causes such well-demonstrated downstream harms, it is up to providers to face this possibility head on.

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