BCBS plans utilize mandated price transparency data to enhance healthcare decisions. Led by Blue Health Intelligence (BHI), the focus lies on leveraging data insights to improve value-based care delivery. Challenges include transforming reimbursement systems and adapting to regulatory changes in interoperability and price transparency. The effort aims to decode complex data, aiding Blues Plans in informed decision-making. Despite progress, consumer-facing tools for accessing pricing data require further development.
Blue Cross Blue Shield (BCBS) plans actively leverage mandated price transparency data, aiming to revolutionize healthcare decision-making. Spearheaded by Blue Health Intelligence (BHI), this initiative focuses on optimizing value-based care delivery. The landscape involves addressing challenges in reimbursement transformation and navigating regulatory shifts in interoperability and price transparency. The utilization of complex data to inform decisions among Blues plans remains paramount, despite the evolving nature of consumer-facing tools for accessing pricing data.
Blue Health Intelligence (BHI), the data and analytics division collectively owned by 17 BCBS affiliates, is at the forefront of this effort. BHI CEO Bob Darin discussed with Becker the utilization of price transparency data by BCBS plans nationwide and the ongoing challenges in this endeavor.
Since July 2022, payers have been mandated to reveal in-network provider rates, out-of-network allowed amounts, billed charges, negotiated rates, and historical net prices for covered prescription drugs administered by providers. Moreover, beginning in 2023, payers had to provide an internet-based price comparison tool enabling members to estimate their cost-sharing responsibility for 500 specific items and services from particular providers, including prescription drugs.
Q: What has been the primary focus of your efforts over the last year as CEO?
Bob Darin: “Our team has focused on using data to address burgeoning healthcare issues, notably enhancing value-based care delivery. Leveraging available data, we collaborate across the healthcare ecosystem to pinpoint areas demonstrating improved outcomes—treating individuals effectively, reducing hospital readmissions, and achieving cost efficiencies. Collaborating with every BCBS plan, we’re identifying care patterns displaying superior quality across various physician specialties. This pioneering effort holds great promise in illuminating factors driving better patient care outcomes.”
Q: Are there specific market challenges or predictions shaping the landscape based on the data you’ve analyzed?
BD: “There’s a persistent drive towards revamping reimbursement systems, transitioning towards valuing outcomes over service quantity. While a long-discussed transformation, recent trends suggest accelerating progress.
Regulatory changes—particularly in interoperability and price transparency—present opportunities. Interoperability regulations are unlocking previously inaccessible clinical data, shaping payment systems, quality measurement, and population management. Our focus remains on integrating this expansive data into our systems.
Additionally, the emphasis on price transparency has prompted us to decode and utilize the published data effectively. We’ve developed robust systems to decipher the complexities, aiding Blues plans in informed decision-making within the market.”
Q: How are you aiding consumers in leveraging this pricing data?
BD: “Standardizing and cross-referencing data from various sources is key. We’re integrating Blues system data, payer publications, and hospital data to discern patterns and discrepancies. This comparison offers insights, empowering organizations to optimize contracting decisions. While these insights are making headway within plans, consumer-facing tools are evolving slowly.
The envisioned consumer empowerment of easily searching for service costs and making informed choices remains a work in progress. The challenge lies in providing comprehensive information about the entire healthcare journey. While strides are being made, it will take time for these tools to become consumer-friendly. The potential for transparent information accessible to all stakeholders, including consumers, is imminent but requires further development.”
In the pursuit of healthcare innovation, BCBS’s utilization of price transparency data stands pivotal. Guided by Blue Health Intelligence (BHI), efforts concentrate on enhancing value-based care delivery while overcoming challenges in reimbursement restructuring and regulatory adaptations. Deciphering intricate data empowers informed decision-making among Blues plans. However, the journey towards user-friendly consumer tools for accessing pricing data continues, indicating ongoing strides toward transparency and improved healthcare decision-making for all stakeholders.