How Price Transparency will Make Healthcare Shopping Easier

This video provides an in-depth exploration of the burgeoning healthcare price transparency movement in the United States, featuring Ahmed Marmoush, CEO and co-founder of Handl Health. The discussion centers on how legislative mandates, particularly the Consolidated Appropriations Act (CAA), are forcing a digital transformation in healthcare by requiring the publication of massive pricing data and the deployment of consumer-facing shopping tools. Marmoush, drawing on his background as a clinical pharmacist in New Zealand's tax-funded system, contrasts the US model's innovation with its complexity, highlighting a personal $800 surprise bill experience that catalyzed the creation of Handl Health. The company's mission is to simplify the chaotic US billing and pricing landscape by empowering consumers—especially those in the underserved middle ground—to shop for care based on both cost and quality.

The core technical challenge addressed by Handl Health is the ingestion and normalization of colossal datasets mandated by the CAA. Marmoush estimates the required machine-readable files (MRFs) contain over a thousand terabytes of data, representing hundreds of billions and trillions of rows of pricing information. Handl Health has developed an automated technology engine to extract, clean, and organize this data, creating digestible endpoints for applications. This engine integrates additional data sources, such as quality metrics from Medicare and third-party vendors, allowing the platform to benchmark prices, make apples-to-apples comparisons, and ultimately calculate a value-based score for providers and facilities. This technical capability moves beyond simple price listing to enable true value-based decision-making for members.

Strategically, the video emphasizes the significant compliance risks and opportunities created by the CAA. The legislation mandates that self-funded employers and insurance carriers must provide a web-accessible shopping tool by January 1, 2023, or face severe fines of up to $100 per member per day. Furthermore, the discussion touches upon the No Surprises Act and the future requirement for Advanced Explanation of Benefits (Advanced DOBs), which shifts the revenue cycle function from post-care billing to pre-service quoting. This legislative pressure is forcing unprecedented collaboration between providers and insurers to agree on total costs of care before services are rendered, condensing a typically 30-to-120-day process into a pre-appointment requirement. Handl Health positions itself as the necessary compliance and value-creation platform for self-funded employers (50 to 4,000 lives) seeking aligned incentives for cost reduction and member steerage. Looking toward the future, Marmoush envisions that the complete transparency of negotiated network rates will lead to a "normalization" of pricing and the eventual dissolution of traditional network structures. This data availability, he argues, will enable a new model of "on-demand insurance," where employers and consumers can custom-design health plans by selecting specific networks or services based on fully transparent costs. Handl Health aims to be the enabling platform for this future, leveraging data to facilitate custom plan design and dynamic steerage.

Detailed Key Takeaways

• Regulatory Compliance is a Massive Data Engineering Challenge: The CAA mandates the publication of machine-readable files (MRFs) containing an estimated 1,000 terabytes of pricing data. Firms must develop sophisticated, automated technology to ingest, clean, and normalize this data to create digestible endpoints for applications, representing a significant data engineering undertaking.
• Severe Financial Risk for Non-Compliance: Self-funded employers and insurance carriers face fines of up to $100 per member per day for failing to implement the required consumer-facing shopping tool or publish MRFs, underscoring the urgency of compliance and the need for robust, reliable software solutions.
• The Shift to Pre-Service Financial Transparency: Future requirements like the Advanced Explanation of Benefits (Advanced DOBs) will fundamentally change the healthcare revenue cycle, demanding that providers and payers collaborate to provide total cost-of-care quotes before an appointment is administered, requiring rapid data exchange and system integration.
• Value-Based Shopping Requires Data Integration: Effective consumer shopping tools must combine pricing data with quality metrics (e.g., Medicare star ratings, appropriateness of care scores) to allow members to make value-based decisions, moving beyond simple cost comparison.
• Intuitive UX is Critical for Engagement: Given that most consumers are not digitally savvy about healthcare, shopping tools must be highly intuitive, accommodating dynamic search methods (by service, provider, or specialty) and potentially integrating non-app methods like SMS/text to drive member engagement and steerage.
• Transparency Fuels New Insurance Models: The availability of all negotiated network rates is predicted to normalize pricing and could lead to the dissolution of traditional networks, enabling the creation of custom, "on-demand" insurance plans designed by employers or individuals based on transparent, known costs.
• Self-Funded Employers are the Immediate Target Market: Self-funded groups (50–4,000 lives) are the ideal clients for transparency solutions because they have the most aligned incentive to reduce total cost of care and leverage steerage tools to improve employee outcomes and financial health.
• Proactive Steerage through Data: Technology platforms can leverage data points like prior authorization requests to proactively identify members searching for care, allowing employers or carriers to intervene with digital or concierge services to guide the member toward high-value, cost-effective options.
• Addressing the "Middle Ground" Consumer: The US system fails the majority of Americans who are insured but underinsured and delay necessary care due to unpredictable costs. Transparency tools are essential to empower this large segment of the population to access appropriate care without financial fear.

Key Concepts

• Consolidated Appropriations Act (CAA): Federal legislation that includes mandates for healthcare price transparency, notably the No Surprises Act and Transparency in Coverage rules.
• Transparency in Coverage (TiC): The CAA requirement that self-funded employers and insurance carriers must publish machine-readable files (MRFs) detailing negotiated provider rates and out-of-network allowed amounts, and provide a consumer-facing shopping tool.
• Advanced Explanation of Benefits (Advanced DOB): A proposed future requirement under the CAA where providers and payers must collaborate to provide a comprehensive, pre-service quote of the total cost of care to the patient.
• Machine-Readable Files (MRFs): Massive, complex data files containing pricing information that must be published by payers, often requiring specialized technology to ingest and interpret due to their size (estimated at 1,000+ terabytes).
• Steerage: The process of guiding or incentivizing health plan members toward high-quality, cost-effective providers and facilities, often facilitated by digital shopping tools.