Perspective: Clinical Workflow, Process Issues Retard Usefulness of Price Transparency
Could issues around clinical workflow and data-related processes in hospitals and health systems make all the difference in whether federal price transparency initiatives succeed? That’s exactly the conclusion that two physician leaders come to, in an analysis published online last month in the JAMA Health Forum.
“The Price Will Be Right—How to Help Patients and Providers Benefit from the New CMS Transparency Rule,” was published in the JAMA Health Forum on Feb. 19 by Jeffrey T. Kullgren, M.D., M.S., M.P.H., and A. Mark Fendrick, M.D. Dr. Kullgren is affiliated with the VA Center for Clinical Management Research at the VA Ann Arbor Healthcare System in Ann Arbor, Mich.; and both authors are affiliated with the Department of Internal Medicine at the University of Michigan Medical School in Ann Arbor; the Department of Health Management and Policy at the University of Michigan School of public Health (also in Ann Arbor); and the University of Michigan Institute for Healthcare Policy and Innovation (also Ann Arbor).
The physicians note that, “On October 29, 2020, the Centers for Medicare and Medicaid Services (CMS), along with the Departments of Labor and the Treasury, issued a final rule on health care price transparency that will, for the first time, require most private health insurance plans to both provide personalized cost-sharing information to patients and publicly report negotiated prices for specific health care services.” And, “Beginning on January 1, 2023, health plans will be required to provide their members with an online tool that will allow them to view these negotiated rates, as well as a personalized estimate of what they could expect to pay out of pocket for 500 of the most ‘shoppable’ health care services (eg, common laboratory tests, outpatient visits, and nonurgent procedures). By January 1, 2024, these shopping tools must report this cost information for all health care services. These new requirements are the culmination of multiple steps outlined in a 2019 executive order to create more transparency in health care, portions of which have faced legal challenges.”
Yet, the authors note, despite the efforts to “standardize the real-time availability of accurate, personalized estimates of patients’ out-of-pocket costs,” many health plans already offer their members tools that provide similar information. Yet those tools are “infrequently used by patients.”
Data-related, interoperability-related, and process-related issues are implicated overall, the authors write. “At the micro level, targeted approaches are needed to enable the routine use of transparent health care price information in health care delivery. First, enhanced integration of health plan data into electronic health record (EHR) systems would allow for the real-time calculation of out-of-pocket costs for specific services. In this scenario, prices for services could be considered alongside other available EHR data, including clinical guidelines and quality measures, so that providers and their patients can gauge and discuss the value of specific services,” they state.
“Second,” they write, “to optimize use of price information, it will also be necessary to develop new clinical workflows that are tailored to different health care environments. For example, in patient-centered medical homes, price information could be accessed and used not only by physicians and advanced practice clinicians but also by other health care team members, such as nurses, pharmacists, or social workers. Any team members who will use price information with patients will need training on how to have effective, patient-centered cost conversations. In health care environments without such a robust team structure, different approaches will likely be needed depending on available resources. When patients use price information to seek services at facilities other than those where they already receive most of their health care, the continued pursuit of EHR interoperability will be vital to minimize the risks of further fragmentation of care.”
Ultimately, they emphasize, “To date, efforts to encourage greater price transparency have been driven by a belief that publicly available information about costs of care would increase market competition, steer consumers toward lower-cost providers, and ultimately constrain, if not decrease, health care costs.” But, without systemic process- and data-related changes, such as changes to how EHRs are organized and connected, and extensive training among clinicians, social workers, and others, the two physician leaders note, patients for the time being won’t benefit from federal regulations designed to empower healthcare consumers through greater pricing transparency.
