Healthcare Price Transparency Data Needs Improvement
Kris Gates
Founder & CEO | Facilitator of Healthcare Innovation @ Lifestyle Health Network
The Health Care PRICE Transparency Act is a bill that aims to make health care costs more transparent for consumers. The bill requires hospitals and health insurance plans to disclose certain information about the cost of care, including:
Hospitals
Insurance plans
Health Plan Price Transparency
Health plan price transparency helps consumers know the cost of a covered item or service before receiving care. As of July 1, 2022, most group health plans and issuers of group or individual health insurance are posting pricing information for covered items and services.
This pricing information can also be used by third parties, such as researchers and app developers to help consumers better understand the costs associated with their health care.
The next requirements went into effect starting on January 1, 2023, providing additional access to pricing information and enhancing consumers' ability to shop for the health care that best meet their needs. The final stage went into effect on January 1, 2024.
What this data means for consumers is that for any item or service I am purchasing, I can request the price of the item or service for a specific provider to compare the most cost effective options.
For app developers, the development of point of care price information for healthcare providers would prompt the cost options for the provider and patient to evaluate.
CMS Enforcement
Beginning July 1, 2022, Centers for Medicare & Medicaid Services (CMS) is to enforce applicable price transparency requirements. For plans and issuers that are subject to CMS's enforcement authority and do not comply, they may take several enforcement actions, including: requiring corrective actions and/or imposing a civil money penalty up to $100 per day, adjusted annually under 45 CFR part 102, for each violation and for each individual affected by the violation.
Public Price Information Required
In three stages, most group health plans and issuers of group or individual health insurance are required to disclose pricing information.
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In-Network Rate File: rates for all covered items and services between the plan or issuer and in-network providers.
Allowed Amount File: allowed amounts for, and billed charges from, out-of-network providers.
The Data Problem
The data problem for app developers is the lack of definition of "Machine-Readable Files". Initially, health plans distributed all data in one file in one line of data. Other health plans, distributed the data in multiple file sets of up to 200+ files per month.
When reviewing the CMS’ enforcement efforts with regard to hospital price data, the Government Accountability Office (GAO) found that, from 2021 through 2023, CMS had initiated 1,287 enforcement actions, about two-thirds of which came in the final year. The enforcement actions most often cited deficiencies related to missing data (43% of actions), no machine-readable file (34%) and noncompliance related to shoppable services or price estimator requirements (33%).
That scrutiny led to more than $4 million in civil monetary penalties issued to 14 hospitals that didn’t address their shortcomings, according to the report. Across 2024, the CMS has posted public notice of only one additional civil monetary penalty, for about $871,000.
The definition of machine-readable files is too broad and does not lend itself to standardization of the health plan data intended to be used in new pricing technologies as it has been interpreted by health plans to essentially mean any data in a file, regardless of whether it is usable/processable in an application.
Kris Gates, [email protected]
Medical Director at Vanguard Medical Group Farmingdale
1 个月Agree with Dr Bonvicino. The monopolies that have been allowed to form with hospital systems, despite the price transparency, are all similarly high priced. So in a monopolistic region its a "take it or leave it" environment as there is no one substantially less costly. Independents were much cheaper but not many if any around in most markets although independent free standing surgical centers, diagnostic imaging centers and urgent care centers often are 5 to 10x's less costly than hospital owned systems. A fundamental change in the structure of payment with a solid independent primary care base would be a good start.
Registered Vascular Technologist, Baptist Medical Center , South
1 个月For the consumer there should be a Blue book value system to be under stood. East coast ,mid west, west coast. Each value simply spelled out. Room rate, same day rate, short stay, etc. surgery by type. Robotic, conventional, minimal, , etc. anesthesia etc, I know it’s simple but most need simple in this red tape system.
Solutions Consultant | Certified SAFe? 5 PO/PM | Senior Clinical Analyst | Strategy, Workflow and Process Optimization Expert | Customer Success | EMR/EHR/Telehealth Senior Product Analyst | Mentor | Oncology EMR Expert
1 个月Thank you Kris Gates for shining light on this! Clean, clear, accessible data will open many doors of improvement.
--clinical advisor
1 个月While allowing consumers pricing it fails to address outcomes and quality and potentially result in collusion so I fail to see the impact on the consumer
Principal at NB Healthcare Advisors, LLC. "Innovative Solutions for Accountable Care"
1 个月While very relevant and important, it is unfortunately, far to late in the game to rely on price transparency alone to reduce the cost of healthcare. We needed this critical information a generation ago, when there was still potential for price competition due to choice and service redundancy in the marketplace. Unfortunately private practice and standalone independent healthcare providers are virtually extinct, having been swallowed up by hospital systems and private equity interests. In the past as an example, one could get advanced imaging or infusion services, at independent physician owned outpatient centers, at a fraction of what hospital outpatient charges. This is no longer possible when hospital systems operate as virtual monopolies in many service areas. If we are to have price competition in the market to lower the cost of care, we need to more than information on price and quality, we need a fundamental change in the marketplace. Without out such a change, I see no alternative then governmental intervention.