As we approach a new year, the healthcare landscape continues to evolve rapidly, shaped by regulatory changes, technological advancements, and shifting consumer expectations. For those entrenched in the healthcare ecosystem, the pursuit of transparency remains a focal point, evolving from a simple aspiration to a fundamental necessity.
2024 will be a pivotal year in the continued movement towards true healthcare transparency. Organizations navigating this terrain will find themselves not only adapting to new regulations, but also harnessing innovative strategies to provide enhanced visibility into healthcare costs, navigation, and outcomes.
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With that in mind, here are a few predictions for what we can expect in the upcoming year for price transparency in healthcare:
There will be fines for not complying with the Transparency in Coverage Rule
In 2023, a significant law, the Transparency in Coverage Rule (TiC Rule), took effect. This law mandated health plan sponsors to disclose their negotiated rates for services and with contracted providers, along with historical payments made to out-of-network providers. However, in January 1, 2023, and even beyond, not everyone was ready with their healthcare price transparency tool. Similar to when the No Surprises Act was introduced in 2022, the government refrained from imposing any fines during the initial year of the law’s enactment.
As the TiC Rule enters its second year, we’ll likely start seeing the imposition of fines at the end of Q3. There are enhancements to the 2023 mandate that expand the scope drastically from offering transparent pricing for 500 medical procedures to nearly all services, which need to be met by January 2024. I expect they’ll give health plans time to roll out the enhanced tool before taking any action. If the past is any indicator though, there will be action taken, and health plans will want to avoid the financial and reputational damage that can come with being the target.
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Smaller plans will be under more pressure
Contrary to popular belief, the initial recipients of fines might not necessarily be the behemoth insurance companies dominating the healthcare landscape. While these industry giants may have struggled initially to provide fully compliant price transparency solutions within their interfaces or public postings in 2023, they’ve made notable strides since then, coming into full or very close to full compliance with the letter of the law.
Conversely, smaller healthcare plans, often operating with more limited IT budgets, are more likely to find themselves in the crosshairs of non-compliance penalties. The lack of widespread awareness among the public about the transparency requirements means many haven’t been feeling the pressure to comply from their members, at least in these initial stages, and they are likely to be further behind in rolling out a solution.
Since the penalty for failing to possess a compliant tool stands at $100 per day per health plan member, these fines have the potential to do irrevocable damage to smaller organizations. These plans will do well to start seriously looking into deploying a price transparency tool if they aren’t already.
Evolving legislation from audits and interpretation variances
Looking ahead, my third prediction revolves around potential updates to the Transparency in Coverage Rule triggered by audits examining compliance discrepancies. The various interpretations of implementing this law have sparked a need for refinements in its enforcement and information disclosure measures.
Advocates are seeking stronger penalties to ensure compliance across the board, urging clearer consequences for failing to meet transparency standards. Additionally, the government has been working on developing more explicit guidelines to define the details health plans should disclose and how they should disclose them, aiming for more comprehensive reporting of pricing data.
With a spotlight on these regulations, and with fans and critics alike looking for more clarity, it is increasingly likely that there will be some changes to existing legislation. As ever, organizations affected by the various regulations need to remain ready and flexible enough to adapt as they are implemented.
Bonus prediction: The rise of empowered healthcare consumers
Anticipate a significant positive shift in healthcare dynamics where consumers take a leading role in their well-being. The collective momentum behind the No Surprises Act and the Transparency in Coverage Rule, coupled with increased public discussion, will continue to drive healthcare towards a consumer-centric approach. This shift promises improved accessibility and encourages open dialogues, fostering a culture where informed decision-making and inquiry become the norm.
As this transformation unfolds, expect a surge in the creation and adoption of user-friendly tools beyond solving for mere compliance, particularly those offering transparent cost information, aimed at aiding consumers in navigating the complex healthcare landscape. While healthcare intricacies often pose challenges, these tools mark a departure from the historical shroud of secrecy surrounding medical expenses and will allow health plans and employers to provide real value to members and perhaps see bigger savings themselves.
Through these growing pains, the healthcare industry will come out for the better
In looking ahead to 2024, the healthcare industry stands at the cusp of a transformative era of transparency. With impending regulatory changes and growing consumer empowerment, the landscape is poised for continued meaningful progress.
This moment presents both challenges and opportunities, urging healthcare entities to swiftly adapt, fostering a future where transparency enables a consumer-driven approach, ultimately reshaping the way healthcare is accessed and experienced for the better.
From the early days of WebMD and other healthcare information sources to an explosion of telehealth providers for both physical and psychological care, consumers are shifting from being pulled into tech-enabled healthcare delivery toward, almost, expecting it. Healthcare is complex, so those that not only make the journey available but also meaningfully accessible will come out ahead.
Photo: Oleksandr Hruts, Getty Images
Mark Stamper is the Vice President of Commercial Products at Opyn Market®. With over 20 years in healthcare and a strong belief in the transformative power of information, he leads initiatives to develop user-centric tools that enable individuals to make informed decisions about their health, driving positive change and improving outcomes.
Formerly at Aetna, Mark held the position of Director of Analytic Consulting and Decision Support. Here, he was the architect and analytic owner of the Coventry Work Comp Outcomes Based Network that identified optimal providers. He also helped design a clinical population health management initiative which made significant improvements in providing patients the right care to achieve the right results at the right cost. Mark's steadfast dedication to innovation and healthcare transformation underscores his ongoing mission to drive meaningful impact within the industry.
