Keeping prices transparent is a very different story for hospitals vs.  Payers - MedCity News

When we look back on this year in terms of price transparency, one thing is abundantly clear: payers and providers face different challenges when it comes to compliance.

This was one of the main takeaways from the end of the year report released Thursday by a price transparency software startup Turquoise health. The report showed that the volume of price transparency data that hospitals must disclose totals about 3 terabytes — compared to the whopping 630 terabytes of data that payers were required to release.

To understand why this is so, we must first look at the recent history of price transparency in the US health care system.

The Centers for Medicare and Medicaid Services has begun implementing it price transparency rule on the first day of 2021. The Act requires hospitals to post their gross charges, payer-specific negotiated charges, de-identified minimum negotiated charges, de-identified maximum negotiated charges and cash prices on their websites in a machine-readable file. It also obliges hospitals to publish prices for the 300 most commonly used services on their website in a user-friendly manner.

The rule was the first of its kind, said Carol Skens, provider and payer strategist at Turquoise. Because the rule did not provide recommended schemas for creating machine-readable files, the first challenge for hospitals was consolidating all the required data elements and publishing them into a single file. Because of this, there is now a lot of variability in hospital machine-readable file data, Skenes explained.

This year CMS began to demand payers to publish price transparency data as well. Implementation began in July.

To simplify the data extraction process, CMS has provided payers with specific schemas to follow when publishing their rate data. Under those guidelines, payers are required to post rate data for more than the services they cover in hospitals — they must post data for all types of providers, such as imaging centers, family practice clinics and ambulatory surgery centers.

“Payers are responsible for including rates for outpatient providers, which greatly increases the size of the machine-readable file,” Skenes said. “In addition, a payer may have unique negotiated rates for thousands of providers to display. All of these factors add up very quickly and make files look clunky or difficult to analyze.

That means payer price transparency data is ripe for innovation, Skens pointed out.

Indeed, in CMS’ payer rule, the agency said it expects “third-party application developers, researchers, regulators, and other file users will have the expertise to summarize, standardize, and interpret the pricing information included in the file and to translate price information into products, market research and surveillance, and reforms that will ultimately benefit consumers.”

Payers still have a long way to go when it comes to compliance, due in large part to the sheer volume of data they must publish. According to Turquoise’s database, 163 US payers have posted their rates. These include big names like Aetna, Blue Cross Blue Shield, Centene, Cigna, Elevance, Humana and United Healthcare. The first payer for which Turquoise found a machine-readable file was Central California Alliance for Health.

Hospitals are finally in a better position when it comes to compliance. More than two-thirds of hospitals have already published machine-readable files with information about their prices.

“This progress means that when mandated, hospitals and payers will follow price transparency,” Skenes said. “Two years is a point in the usual timeline of the healthcare industry looking to make fundamental changes. We are thrilled to see how much has been achieved in such a short time.”

Photo: eichinger julien, Getty Images

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