Electronic Health Reporter

By Rahul Ajmera, SVP of Provider Market, CitiusTech.

Over three years since U.S. healthcare providers and payers adopted new cost transparency regulations designed to make healthcare costs more accessible. While the intent behind these regulations is in empowering consumers to compare prices across various healthcare services and insurance options, many healthcare organizations continue to struggle or are hesitant in achieving full compliance.

This article aims to quickly decode & rethink the importance of price transparency rules for healthcare organizations, with a change in mindset–embracing it not only as a regulatory requirement but also as a pivotal chance for enhancing care services, improving patient experience, and gaining a competitive edge.

Understanding the compliance gap

The journey to compliance has been slow for some either since pandemic-related disruptions or owing to resource limitations. Many organizations still find it difficult to navigate the intricacies of these regulations, which require a comprehensive overhaul of existing data management practices. The process involves consolidating diverse data sets from various systems and ensuring they are structured appropriately for public disclosure–additionally, a demanding skill set from IT, if they are already overstretched. But before we dive into the complexities, it is due to note that if compliance becomes more widespread, organizations may discover new avenues for more than just operational improvements through careful analysis of the data generated, lead to better patient experience and give competitive edge.

Opportunities for improvement

The push for price transparency presents not just challenges but also opportunities. By making pricing data readily available, hospitals and insurers can facilitate better consumer understanding of direct expenses made. Moreover, the new pricing landscape allows organizations to leverage data analytics at a vantage point. By utilizing data-driven insights gleaned from commercial rates that payors are mandated to publish, healthcare providers can identify reimbursement rates in their participation agreements that are too low relative to what other providers are receiving.

Access to the new price transparency data opens opportunities to modernize and expand traditional health data models to incorporate and analyze vast amounts of unstructured pricing data, offering real-time insights and personalized recommendations to consumers. Advanced analytics and Generative AI can be leveraged to optimize supporting documents for claims, and to simplify complex medical billing correspondences, making it easier for patients to understand costs.  An established technology known as Knowledge Graphs can be incorporated with Generative AI to link related data points, ensuring that pricing information is not only accurate but also contextually relevant, driving better decision-making for both providers and patients.

Turning data into a strategic asset

With the right analytical tools in place, organizations can benchmark their prices against industry standards and uncover opportunities to optimize provider’s reimbursements. Employers can access the data to advocate for more cost favorable health plan options. Once the price comparison data becomes more easily accessible to consumers, they will be able to make more informed decisions about where to access care which can reduce their out-of-pocket expenses.

Tackling data management complexities

Back to the foundation, to effectively manage the requirements of price transparency, the importance of overcoming data management-related roadblocks cannot be overstated. These include issues related to siloed information within legacy systems and ensuring data quality for analytics. Embracing standardization tools and utilizing cloud-based solutions can help streamline data collection and analysis. Here, the right cloud service providers can offer the necessary infrastructure to support large data sets, enabling organizations to process and maintain compliance efficiently. Further, leveraging tools designed for data slicing and analysis can provide healthcare organizations with the flexibility needed to adapt to evolving regulatory demands.

Looking ahead at a data-informed future

While many healthcare leaders currently prioritize the implications of price disclosure, a shift in perspective is on the horizon. As healthcare organizations begin to increasingly depend on data-driven insights from pricing information, we can expect to see tactical optimization of strategies that contribute to a more informed healthcare landscape. However, the data is vast and cumbersome and requires a strategy to employ it to optimize organizational goals.  Once we begin relying on data driven contracting and purchase decisions based on the open access to real pricing data, opportunities will present to reshape the healthcare landscape into one that prioritizes economic sustainability, accessibility, quality, and equity in care outcomes.