Finding the rates of mutual health care is an ordeal: Rants


Insurers are complying with federal rules aimed at price transparency that went into effect July 1, but consumer use of the data may have to wait for private companies to synthesize it.

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Insurers are complying with federal rules aimed at price transparency that went into effect July 1, but consumer use of the data may have to wait for private companies to synthesize it.

DNY59/Getty Images

Data buffs with powerful computers are delighted. Ordinary consumers, not so much.

That’s the reaction about three weeks after a data dump of enormous proportions. Health insurers post their negotiated rates for just about every type of medical service they cover with every provider.

But so much data is coming in from insurers – tens of thousands of colossal digital files from a single insurer is not unusual – that it could still be weeks before data companies put it into usable forms. for the intended targets: employers, researchers and even patients .


“There’s data out there; it’s just not accessible to mere mortals,” said Sabrina Corletteresearcher at the Center for Health Insurance Reforms at Georgetown University.

Insurers are complying with federal rules aimed at price transparency that went into effect July 1, she and others said. Realistically, however, consumer use of the data may have to wait for private companies to synthesize it — or for additional federal requirements to start coming into effect next year aimed at allowing consumers to use more easily price information for purchasing scheduled medical care.

So why post prices? The theory is that publicizing this range of prices, which are likely to vary widely for the same care, will help moderate future costs through competition or better price negotiations, although none of this is a guarantee. .

Last year, hospitals were subject to a similar directive, which stems from the Affordable Care Act, to publish what they have agreed to accept from insurers – and how much they charge paying patients in species. Yet many dragged feet, saying that the rule is costly and time-consuming. Their professional association, the American Hospital Association, pursued in vain to stop it. Many hospitals have simply never complied, and federal government enforcement has proven lax.

As government regulators sent over 350 warning letters to hospitals and increased potential civil fines from $300 a day to $5,500, only two hospitals have been fined so far.

The requirement for insurers is broader than that faced by hospitals, although it does not include spot prices. It includes negotiated rates paid not only to hospitals, but also to surgery centers, imaging departments, labs, and even physicians. Amounts billed and paid for “out-of-network” care are also included.

Fines for failing to publish can be higher than those facing hospitals — $100 per day per violation, per affected registrant, which adds up quickly for mid-size or large insurers or self-insured employers.

“We are seeing high compliance rates because of the high penalties,” said Jeff Leibachpartner of the consultancy firm Guidehouse.

Difficult to access information

The data is published on public websites, but it can be difficult to access, mainly because of its size, but also because each insurer approaches it differently. Some, like Cigna, require potential viewers to cut and paste a very long URL into a browser to access a table of contents of price files. Others, including UnitedHealthcarehave created websites that directly list a table of contents.

Yet even the tables of contents are enormous. The UnitedHealthcare webpage warns that the page may take “up to 5 minutes to load”. When this is the case, there are over 45,000 entries, each listed by year and plan or employer name for employment-based policies.

For consumers, accessing any single plan would be a challenge. Right now it’s also difficult for employers, who want to use the information to determine how well their insurers are negotiating relative to others.

Employers “really need someone to download and import the data,” which is in a format that can be read by computers but isn’t easily searchable, said Randa Deatonvice president of buyer engagement at the Buyer Business Group on Health, which represents large employers.

After a first look, she saw a wide variation in costs.

“In one plan, I could see negotiated rates ranging from $10,000 to $1 million for the same service,” Deaton said.

But the big picture won’t be clear until more data is cleaned up: “The question is what story is this data going to tell us.” she says. “I don’t think we have the answer yet.”

Policymakers in Congress and the administration expected data from insurers to be overwhelming and private companies and researchers to step in to do the in-depth analysis and data generation.

One of these companies is Turquoise Healthwho was “thrilled with the amount of data,” said Marcus Dorstel, vice president of operations.

The company, one of several companies aiming to commercialize the data, had uploaded by mid-July more than 700,000 unique files or about half a petabyte. For context, 1 petabyte is the equivalent than 500 billion pages of standard typescript. His expectation, Dorstel added, is that the total download will end up in the 1-3 petabyte range.

Turquoise soon hopes to share curated data with its paying customers — and offer it free to mainstream consumers sometime later on its website, which already lists available hospital prices.

what you can do now

What is possible right now?

Let’s say patients know they need a specific test or procedure. Can they look online for data published by insurers to choose a treatment site that will be most profitable, which could be helpful for those who have not yet paid their annual deductible and need to pay some or all Cost ?

“Perhaps a person with a laptop could look at one of the files in a plan,” Dorstel said, but consumers would have a hard time comparing between insurers — or even between all the plans offered by one. sole insurer.

Consider, for example, what it takes to try to find the negotiated price for a particular type of brain scan, an MRI, from a specific insurer.

First obstacle: finding the right file. Google “transparency in coverage” or “machine readable files” with the name of an insurer and the results may appear. Self-insured employers are also expected to publish the data.

Next step: Find the exact plan, often from a table of contents that can include tens of thousands of names, because insurance companies offer many types of coverage products or have many employer customers who also need be listed.

Then download and decipher the tangle of codes to identify one describing a specific service. It is useful to have the service code, something a patient may not know.

From January 1, another rule comes into effect that could bring some relief to consumers.

This involves the apps and other tools that some insurers already provide to policyholders so they can estimate costs when preparing for a visit, test or procedure.

The new rule strengthens the information available and requires insurers that do not offer such tools to have them ready by that date. Insurers must make available online, or on paper, if requested, the patient’s cost for a list of 500 selected by the governmentcommon “purchasable services” including knee replacements, mammograms, a host of types of x-rays and, yes, MRIs.

The following year – 2024 – insurers must provide consumers with the cost-share amount for all services, not just the first 500.

An explanation of the benefits and a price comparison

Another regulatory layer stems from the law without surprises, which came into force this year. Its main objective is to reduce the number of insured patients who receive higher than expected care bills from out-of-network providers. Part of the law requires providers, including hospitals, to give a “good faith estimate” for non-emergency care when asked. Currently, this part of the law only applies to patients who are uninsured or using cash to pay for their care, and it’s unclear when it will start for insured patients using their coverage benefits.

In this case, insurers will be required to provide policyholders with cost information before they receive care in a format described as an Advance Explanation of Benefits – or EOB. This would include how much the provider will charge, how much the insurer will pay – and how much the patient will owe, including any unpaid deductible.

In theory, that means there could be both an initial EOB and a price comparison tool, which a consumer could use before deciding where or from whom to get service, Corlette told Georgetown.

Still, Corlette said she remains skeptical, given all the complexities, that “these tools will be available in a usable format, in real life, for real people anywhere near the envisioned timeline.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).


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