Price Transparency Act Needs Work. Shouldn't it be a "price calculator" instead of "price posting"?

U.S. President Donald Trump issued an executive order to improve price transparency of healthcare costs on Tuesday by requiring the enforcement of a 2019 price transparency order he signed during his first term.

The order directs the Departments of the Treasury, Labor, and Health and Human Services to produce a method for enforcement of Trump's 2019 executive order to force health insurers and hospitals to disclose healthcare cost details within 90 days.

Hospitals

The 2019 order required hospitals to maintain a consumer-friendly display of pricing information for up to 300 shoppable services and a machine-readable file with negotiated rates for every single service a hospital provides.

Hospital groups have already unsuccessfully challenged the order in court after arguing it forces them to disclose private negotiations with insurers, undermining competition and violating their First Amendment free speech rights, all claims dismissed by the court.

Hospitals made a good faith effort to comply, but the burden is bigger than just listing prices.

Why?

• Prices are negotiated with each payor and even small hospitals have at least 20 payor contracts with negotiated rates
• Usually discounts are applied for employees
• Self-pay has a different rate
• Charity care policies impact rates due to discounts or waivers
• Charemasters, other than rural hospitals, are out of date
• Also, no standardized format has been proposed for the definition of machine-readable. Perhaps the best option is for a Fast Healthcare Interoperability Resources (FHIR) standard needs to be refined for this use case.

Solution: All of the above issues need to be addressed before a "price posting" can occur. Instead of price posting, it should be a "price calculator" taking into account all of the above factors.

https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency

Health Plans

The executive order also required health plans to post their negotiated rates with providers, their out-of-network payments to providers, and the actual prices they or their pharmacy benefit manager pay for prescription drugs; and to maintain a consumer-facing internet tool making price information accessible.

Health plans did not make a good faith effort, instead the data sets released are mostly unusable due to the format the health plans put the data into. For example, one row of data with a million points of data.

https://www.cms.gov/priorities/key-initiatives/healthplan-price-transparency

Solution: Require health plans, including Medicare, to put the data in a bulk standardized format of Fast Healthcare Interoperability Resources (FHIR) format.

Kris Gates, [email protected]

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