Editor's Note: We are on the cusp of a transparency revolution in which consumers will have the data and tools to make informed choices among their health insurance options in ways that will transform the Marketplace. In a new white paper prepared for Novo Nordisk, summarized below, Manatt Health describes a four-year Roadmap to Transparency that will allow consumers to make informed decisions that address their unique healthcare needs and reflect their unique preferences across the dimensions of cost, quality and access. To download a free copy of the full white paper, click here.
The federal and state Marketplaces established by the Affordable Care Act (ACA) have made it easier for consumers to compare their health insurance options. Data are still not fully available, however, for consumers to understand how their plan options compare on cost-sharing, provider networks and drug access, as well as how much each option might cost them in premiums and out-of-pocket spending. The challenges are more daunting for consumers who purchase coverage outside the Marketplace, where comparative data are harder to find and consumer tools are more limited.
Despite these limitations, the road ahead is clear. We are on the verge of a transparency revolution that will ensure consumers have the right information at the right time to make informed decisions on their choice of plan design; formulary; network; provider; and cost of treatment, ideally including comparative costs when consumers are asked to choose among competing treatments.
Eventually, a vibrant health insurance Marketplace should also enable consumers to incorporate personal preferences on physician and hospital choices, to examine the estimated costs of a particular treatment or service across competing providers and/or health plans, and include these estimates—and the associated out-of-pocket liabilities—in their decision support calculations.
By 2020, consumers should be able to use a decision-making tool or multiple tools, as envisioned in the following scenarios:
- A person with diabetes uploads his electronic medical records and biometrics from his wristband to a consumer tool that matches this individualized data against all available health plans and within minutes provides detailed plan rankings based on expected cost (premium and predicted cost-sharing), provider and drug access, patient satisfaction ratings, or other factors of the person's choosing.
- A millennial in a hurry enters her age and zip code into a mobile app and within seconds can view the three cheapest plans by premium in her area. The app encourages her to enter income to see whether she is eligible for a subsidy and health data to estimate her out-of-pocket expenses.
Realizing the Vision: A Four-Year Roadmap to Transparency
The Roadmap to Transparency is a four-year plan that describes the steps that public officials and private stakeholders can take to realize the full benefits of a Marketplace in which consumers have ready access to online decision-support tools that:
- Allow electronically searchable plan comparisons by plan characteristics, including benefit design, cost-sharing, network and formulary.
- Allow—but do not require—consumers to input personal data into the tool, including health conditions, prescriptions and provider preferences.
- Allow—but do not require—consumers to elect auto-uploads from medical records/claims, as well as wearable devices, such as heart rate monitors, to auto-enable recommendations for the best plan, based on the consumer's unique preferences.
Eventually, consumers should also have access to tools that allow them to:
- Assess and screen for the reported quality of providers and determine which plan's network is best for their needs.
- Compare the cost of different treatment options (i.e., how much knee surgery will cost vs. alternative treatments).
The Roadmap focuses primarily on the foundational step of making health plan information available in a standardized and timely manner, so the designers of consumer tools have full access to the data necessary to develop robust decision-support tools. These data are already being collected by state and federal regulators, some of it in machine-readable formats that are readily usable for app development. The rest could be made equally accessible, though it will take effort to ensure the data meet six key criteria for data quality:
- Accurate—verified information that reflects actual plan offerings.
- Complete—available on all plan offerings in all relevant product categories.
- Consistent—available in standard formats that allow for apples-to-apples comparisons.
- Accessible—publicly available so that tool designers compete on a level playing field to use the data to fashion consumer tools.
- Processable—available in machine-readable formats that can be easily manipulated, so that tool designers can turn an overwhelming amount of data into consumer-friendly decision-making tools.
- Timely—available in advance of open enrollment.
The Roadmap's Three-Pronged Approach
The Roadmap outlines a three-pronged strategic approach to achieving the requisite data quality and ensuring that consumers are able to benefit from the results:
- Take concrete action to make key data on plan design, provider networks and formularies available to app developers;
- Continue to focus on developing a regulatory environment that promotes innovation in app development, safeguards consumers' privacy rights, and ensures fair competition; and
- Develop consumer literacy campaigns that promote consumer use of health-related apps and other decision-support tools so consumers can understand their options and make choices that most find bewildering today.
Four Key Recommendations
The Roadmap includes four key recommendations designed to establish the data foundation for a transparent and consumer-oriented Marketplace by 2020:
- Federal and state regulators should work together to make full data on all Marketplace plans publicly available in machine-readable standardized formats at least 60 days prior to open enrollment each year.
- State insurance regulators, with the assistance of the National Association of Insurance Commissioners (NAIC), should ensure that the same plan data that are made available for public Marketplaces are made available in the same machine-readable standardized formats for the rest of the individual and small group markets.
- The Department of Health and Human Services (HHS) and state officials should jointly convene an advisory group of public and private experts to establish best practices and, potentially, regulatory standards for the use of data by choice-enabling applications.
- State and federal officials should collaborate with private payers to expand access to large claims databases and to pricing and quality data on medical services.