Lauren Riplinger, JD
The overall cost of healthcare is top of many Americans’ minds these days. According to a March 2021 Gallup poll, 80 percent of respondents worry about the availability and affordability of healthcare a “great deal” or a “fair amount.”1
Today, most Americans have coverage through their employer or a public program, such as Medicare or Medicaid. However, in 2019, 28.9 million individuals were uninsured. At the same time, healthcare costs have continued to increase. Much of this cost has been passed along to individuals in the form of higher premiums, deductibles, and other forms of cost sharing.
As the cost of care rises, policymakers have increasingly focused on the need for greater transparency in healthcare prices and health plan coverage.
In 2009, the Affordable Care Act introduced the industry’s first requirement for hospitals to make available their list of standard charges for items and services. More recently, under federal rules issues by the Trump administration, the Centers for Medicare and Medicaid Services (CMS) required hospitals to publish the price of 300 health services that can be scheduled in advance. These prices must also be made available in a “machine-readable file” on the hospital’s website. The intention of this rule is to enhance the ability of individuals to make more informed decisions based on costs.
Additionally, policymakers have focused on how technology may be leveraged to help individuals better understand healthcare prices. Both the CMS Patient Access and Interoperability Rule and the ONC Cures Act Final Rule encourage the adoption of application programming interfaces (APIs) and modern technical standards that could support the development of highly customized pricing tools for consumers.
To ensure that the health information (HI) perspective is a part of these discussions, AHIMA’s Board of Directors recently approved a public policy statement on affordability. In approving the statement, the board affirmed its belief that “AHIMA supports the use of public policy to ensure that individuals have all the information they need to make informed choices about their healthcare. This includes both access to their personal health information and actionable information about the cost of their healthcare.”
The public policy statement identifies five key recommendations for policymakers to support the ability of individuals to make informed decisions about their healthcare:
- Support individuals in accessing both their personal health information and actionable information about the costs of their healthcare.
- Support the development of accurate, useful, real-time tools to inform individuals of their healthcare costs.
- Find equitable solutions to prevent “surprise billing” for consumers.
- Maintain the privacy and security of health information, including when it is shared with third parties.
- Support education for consumers, regardless of their financial situation, on how to understand their health plan coverage and ask for the information they need to make informed decisions.
In developing this public policy statement, AHIMA brought together a member work group to understand key considerations associated with improving individuals’ access to their personal health information and actionable information about the costs of their care. This included discussions around the key challenges associated with providing individuals with information to support affordability, such as changes in health plan coverage and billing rules and the barriers associated with individuals understanding their out-of-pocket costs.
Policy discussions around affordability are expected to continue in the current Congress and the Biden administration. Initial results related to implementation of the CMS Price Transparency Rule have found that: current price estimates provided by hospitals do not always allow for accurate comparison, price estimates change over a short period of time, pricing information provided in machine-readable files is not complete, and at times, pricing information is hard to access or comprehend.2 At the end of last year as part of the Omnibus Appropriations and Emergency Coronavirus Relief Act, Congress also included The No Surprises Act, which seeks to protect consumers from surprise billing in certain circumstances. Regulatory work will need to be done to implement these provisions. As these debates continue in Congress and within the federal agencies, AHIMA stands ready to lend its perspective and expertise to the conversation.
Work Group members
- Terri Eichelmann, MBA, RHIA, Director, Enterprise Coding and HIM Technology Support, BJC HealthCare (Board member)
- Judy Kelly, RHIA, CPHI, CHDA, CCS-P, CCS, Senior Director, Health Information Management, Rochester Regional Health
- Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, CPC, FAHIMA, Former Manager of Clinical Data, Advocate Health Care
- Charniece Martin, MBA, RHIA, CCS, CCS-P, Healthcare Coding Analyst, American Medical Association
- Jennifer Goins, MHA, RHIA, Managing Consultant, BKD Health Care Performance Advisory Services
- Anny Yuen, RHIA, CDIP, CCS, CCDS, Consultant/Principal, AP Consulting Associates, LLC
- Laura Pait, RHIA, CDIP, CCS, Director, Strategic Realization and Implementation, Enjoin
- Mary Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, Vice President Consulting Services, United Audit Systems, Inc.
- Gallup. “In Depth: Topics A to Z, Healthcare System.” https://news.gallup.com/poll/4708/Healthcare-System.aspx.
- Kurani, Nisha, Giorlando Ramirez, Julie Hudman, Cynthia Cox and Rabah Kamal. “Early results from federal price transparency rule show difficultly in estimating the cost of care.” Peterson-KFF Health System Tracker. April 9, 2021. https://bit.ly/3293PJO.
Lauren Riplinger (email@example.com) is vice president of policy and government affairs at AHIMA.