Payers have been subject to price transparency regulations since July 2022, but no comprehensive action or research has taken place since then to assess compliance, according to research published Sept. 19 in Health Affairs.
The two authors are from the Hilltop Institute, a nonpartisan research organization at the University of Maryland in Baltimore. They wrote that compliance research occurred within months of hospitals facing a similar rule that took effect in 2021, but insurers have not faced the same scrutiny.
"We posit that this lack of compliance monitoring is not for lack of interest but rather because of the complexity of the landscape to which the regulation applies," they wrote.
Six key takeaways:
1. One of the first issues with assessing payer compliance is that a mixture of states and federal agencies are responsible for enforcement, depending on the type of health plan.
2. Another key issue with monitoring compliance is that who the rule applies to is not a straightforward answer. Technically the rule applies to group health plans and health insurance issuers, but those two groups often "overlap and interconnect, as do the entities responsible for complying with the [price transparency] rules on their behalf."
3. Regulators did anticipate these overlaps and the regulations address potential redundancies.
4. There are key barriers to identifying all organizations that are required to publish pricing data: The scope of self-funded and fully-insured ERISA plans across the country is not publicly available; and the agreements and data relationships between group plans and issuers or third-party administrators are also not publicly available.
5. Despite the barriers, it is known which payers participate in the individual, small and large group markets, along with ERISA group plans with 100 or more individuals.
6. The authors offered three compliance assessment suggestions for researchers and regulators: Assess compliance in the individual market as a start; use Form 5500 Schedule A data to identify which payers large-group ERISA plans are contracted with; and update the transparency regulations to require group health plan sponsors to disclose agreements with payers or TPAs.
"The wealth of compliance studies for the hospital price transparency rule may have stimulated hospital compliance and moved the needle on state legislation. The clock is ticking on the [payer] rule—with health care costs continuing to rise, regulators and agencies must get serious about enforcing compliance if this promising new data source is to have a meaningful impact on national health care spending," the authors concluded.