Health systems and health insurers should prepare for the potentially significant shifts in the industry that the federal health data interoperability and price transparency mandates can generate, or else risk losing out to more innovative players.
The Interoperability and Patient Access rule removes the barriers to sharing patient data with new entrants in the healthcare market and can reduce the friction of changing health plans — creating a more fluid, mobile customer base. This can spell trouble for member retention and satisfaction. At the same time, the Hospital Price Transparency and Transparency in Coverage regulations lift the curtain on insurance and medical care costs, potentially raising uncomfortable questions for payers, providers and pharmacy benefit managers along with fresh headline risk.
Arming consumers with data ownership and price information, along with the rapid liberalization of healthcare data at large, may generate seismic changes within the industry:
- Explosive growth of well-funded apps that allow consumers to absorb and interpret healthcare data. These could potentially replace traditional payer services of finding clinicians, providing care management and interpreting medical cost/value.
- Heightened competition and conflict across health systems, payers, regulators and new entrants as price transparency reveals massive inefficiencies and inaccuracies in the healthcare market, while making it easier for consumers to shop based on cost and value.
- The potential for consumers to begin to explore innovative, more affordable, tailored insurance options that aren’t rooted in employer-based coverage and/or for employers to feel more comfortable opting not to manage employee health benefits.
- Consumers’ ability to quickly and easily share their healthcare data with their family and care team, which is critical to creating empowerment for patient-centered and holistic care.
Health systems and payers can recognize and act on the opportunities this disruption presents. By helping consumers become empowered through their data, organizations can help to advance the Quadruple Aim of improving healthcare quality, cost and experience for members and providers. Outcomes can improve and costs go down when patients are informed and engaged in their care. Additionally, patients and care providers can have a better experience when they are partners in the care journey.
We believe health systems and payers can take specific actions now to position for success:
- Build trust and foster engagement: CMS is planning to create awareness around these new capabilities and regulations. Payers and health systems are poised to lead the conversation on data access and transparency in their communities. They can build trust among patients by educating and engaging them on where to find their data, what it means, and how they can use it to partner with their care teams to help improve their healthcare decision-making. Being forthcoming with employer groups on what to expect around the flood of pricing data can preserve trust in the face of headline risk. Organizations that help their constituents understand and use all of this new data will effectively navigate this change and convert it into a competitive advantage.
- Beat third parties to the punch: Payer and provider organizations should grab the reins on providing valuable services to consumers by creating or licensing tools that provide patients and employers with a quality view of data and education. Ceding that role to third-party apps means not only missing a chance to create value and enhance trust but also losing an opportunity to curate the content and the message. The worst is to be seen as caught off guard and scrambling for damage control. The media can assuredly latch onto this new price information, reporting for weeks or months.
- Stay ahead of the curve: In a healthcare ecosystem driven by application programming interfaces (API), change will happen fast, and payers and health plans need to make sure they’re not just responding to other players’ moves. They should identify an owner in the organization who will stay connected in real time to developments, such as new entrants or services. Working with firms like PwC can help in scanning the market and formulating contingencies and capital allocation to fund responses.
- Embrace the mission: Organizations should recognize the spirit and intent of these regulations: Inaccessible data and hidden pricing policies schemes have contributed to a highly inefficient U.S. healthcare market without clear value for patients. Payers and providers that treat this as a compliance exercise can soon be at the mercy of those that embrace the potential of patients empowered with data. This truth, along with the savings in reduced administrative burden and zero waste cost of care, make this opportunity both a business- and mission-driven endeavor.
These mandates are not regulators’ first attempt to shift the market toward value-based care and improved consumerism. However, unlike past efforts that have come up short, these new rules put the most important player in the equation — the patient — back in control. Patients can look at their whole continuum of care and the data, including costs, that surround it. That can change the way they interact with payer and provider organizations, the way they make decisions, and their expectations. Payers and health systems that look beyond compliance and begin preparing for these changes can be best positioned for success. Those that don’t do so at their own risk.
For more insights and to learn more, please contact us at us_healthindustries@pwc.com.
© 2021 PwC. All rights reserved. PwC refers to the US member firm, and may sometimes refer to the PwC network. Each member firm is a separate legal entity. Please see www.pwc.com/structure for further details. This content is for general information purposes only, and should not be used as a substitute for consultation with professional advisors.