How BCBS plans are putting price transparency data to work

It's been nearly two years since payers have been required to publish the costs of their in-network provider rates for covered items and services, and now Blue Cross Blue Shield plans are using that data to create actionable insights for stakeholders across the healthcare system.

Much of that work is being done by Blue Health Intelligence, the data and analytics arm of the BCBS Association that is collectively owned by 17 BCBS affiliates. Becker's sat down with BHI CEO Bob Darin to learn how Blues plans around the country are utilizing price transparency data, and the major challenges that still lie ahead.

Since July 2022, payers have been required to disclose in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for all covered items and services, and negotiated rates and historical net prices for covered prescription drugs administered by providers. Starting in 2023, payers had to provide an internet-based price comparison tool that allows members to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers for 500 items and services. Price comparison tools must include all services, including prescription drugs, starting Jan. 1.

Question: What has been the primary focus of your efforts over the last year as CEO?

Bob Darin: One thing we embarked on as a team over the last year is using data to tackle some of the fastest growing and emerging healthcare issues. One of those that we get a lot of feedback on is how to continue investing in the improvement of value-based care delivery. With the data we have, we can work across the healthcare system to identify the parts that are delivering better outcomes: getting people treated, not readmitted to the hospital, and with lower costs. For the first time ever, we're working with every Blue Cross plan in the country to identify those patterns of care that show the highest quality across multiple physician specialties. We're really excited about that and we think there's a lot more ways to go on how we use the data to shed light on what drives better care outcomes for patients.

Q: Are there certain market challenges or predictions you foresee shaping the landscape next year based on the data you've been looking at?

BD: There's a continued focus on improving the reimbursement system and shifting to value for outcomes rather than value for more services delivered. It's a long journey that's been talked about for several decades, but it is starting to get a lot of acceleration. 

We think there's also opportunities that are being brought by a number of regulatory changes in the past several years, in particular, interoperability and price transparency. How do we get the data that is primarily locked in physician electronic medical systems and make it accessible across the system? Interoperability regulations are making new types of data available that weren't in the past, such as clinical data and using that as part of your payment system, how you're measuring quality and how you're managing at-risk populations. There's an enormous amount of work that's going on in that area and we're just starting to build our system that can take it all in.

The other big regulatory change we spend a lot of time on is price transparency. We are now working with the Blue Cross system to actually use the data that's published and make it more digestible, thereby helping people make better decisions. We now have a very robust system to understand the different trends and variations in public transparency data. This data is massive, complicated and hard to digest, so we have spent a lot of time deconstructing it. Now we're using it actively to help the Blues plans make better decisions around what's in the market. 

Q: How are you helping consumers take advantage of this pricing data?

BD: There is no silver bullet here and this is not a quick project, but we are making a concerted effort to standardize the data and match it against other sources of truth. We have the data for the Blues system, what other payers have published and what hospitals have published. We've started to match it all against each other and you start to get a picture, along with a sense of which data seems reasonable and which doesn't. Pictures are not a definitive answer, but you can see very clear patterns. For example, organizations can see if they are systematically different from the rest of the market when contracting for a service and they can act on it. The more advanced plans we work with are starting to act. Most of the insights help to better understand competitive market dynamics or what's going on locally with contract negotiations. 

Less of these insights have made their way to consumers. I think when these regulations were written, people thought it was going to unleash being able to search for how much a service cost and then you'd be able to shop for it. We're not there yet and there's a couple of reasons for that. One is that it's usually not just an individual procedure you receive, you need to know what the entire journey is going to be. The industry is still trying to figure out how we put it all together to help consumers in a meaningful way, and we've got some pilots underway with that. There's a lot of opportunities to build and I think these tools are coming. Over time, we're going to get more transparent information, not just for providers, insurers and brokers. The consumer revolution is coming, it's just going to take a bit longer.

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