How Patients and Providers Can Benefit from the New Price Transparency Rule

On October 29, 2020, CMS, along with the Departments of Labor and Treasury, issued a final rule that will require most private health insurance plans to provide personalized cost-sharing information to patients and publicly report negotiated prices for specific health care services.

Beginning on January 1, 2023, health plans must provide an online tool that allows members to view these negotiated rates and a personalized estimate of what they can expect to pay out-of-pocket for 500 of the most “shoppable” health care services (eg, common laboratory tests, outpatient visits, and non-urgent procedures). By January 1, 2024, these shopping tools must report this cost information for all health care services.

Enhancing the Integration of health plan data into electronic health records would allow for real-time calculation of out-of-pocket costs for specific services. So providers and patients could consider prices, alongside clinical guidelines and quality measures, to gauge the value of services, according to an article in The Journal of the American Medical Assn. by Jeffrey T. Kullgren, MD, MS, MPH and A. Mark Fendrick, MD.

While providing prices is essential, additional steps are needed to ensure that this new policy results in more efficient care delivery, and, most importantly, improved patient-centered outcomes. Messaging from health system leadership and professional societies could encourage providers to view cost conversations with patients as a core professional responsibility. Some will need new skills to consider prices in their clinical decision-making,

It will also be necessary to develop new clinical workflows that are tailored to 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 nurses, pharmacists, or social workers.