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Formulary guidance and transparency from P&T to point of care

Perspectives on Healthcare Transparency

Posted by Matt Breese on Oct 27, 2015

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As healthcare goes digital, payers, providers, and manufacturers have an opportunity to provide transparency into the healthcare network. Although healthcare stakeholders have incentives to create more transparent solutions, driving industry forces create an overwhelming opportunity cost in some cases. 

When it comes to payers and coverage of pharmaceutical treatments, consumers and providers demand insight into their plans. As health plans evolve into digital products, consumers and HCPs view their drug access online. Although many elements factor into choosing the right plan, pricing on drug coverage for relevant medical conditions can complicate one’s decision. As consumers may not have a basis to understand the reasoning for pricing in the current system, many payers advocate for value-based reimbursement as a way to promote superior transparency. Twenty leading health plans have committed significant portions of their businesses to value-based arrangements.

Additionally, the legal system advocates for reform. In order to facilitate better leadership, eleven legislators prompt Medicare to provide more drug payment transparency. The lawmakers emphasize proper reporting of pharmacy price concessions, which would give CMS more oversight for Medicare Part D plans. The proposed guidance mandates the standardization of price concessions received from pharmacy networks and incentive payments from Medicare health plans. As part of the prompt, all additional or unlisted fees must be detailed or estimated. Ideally, this will allow the nation's senior population to make more informed decisions.

Improving patient access to data will also improve providers’ ability to ensure patients receive the most appropriate medication. As the issue stands today, consumers have dual issues; firstly, they lack the necessary information to make educated medication purchases and, secondly, have trouble making the most optimal decisions even when they have the tools to do so.  Commenting on a recent study performed by economists from Berkeley and Harvard, Ron Shinkman of FierceHealthFinance describes that conditioning from doctors, distress from health and inexperience with pricing tools will prevent patients from optimally managing their healthcare. Although consumers will not make informed decisions even with more transparent data, they will not start learning until they have increased access to the information.  

Although improving transparency will provide numerous benefits, too much transparency can cause additional problems. In a piece on the 340B program, Drug Channels argues that this legislation gives the HRSA (Health Resources and Services Administration) aggressive oversight over pharma’s specialty channel strategy through the façade of compliance audits. This change could result in a loss of competitive advantage for some manufacturers, as the HHS (U.S. Department of Health and Human Services) would have the authority to review and publish their strategies.

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Topics: Specialty, Industry Trends, Market Access