June 3, 2025 • 40 mins
Jackie Selby, Partner, Epstein Becker & Green PC, Maria Nikol, CEO, Revelar Analytics LLC, and Karen Mandelbaum, Senior Counsel, Epstein Becker & Green PC, discuss current trends and developments related to price transparency. They cover why price transparency is important; provide an overview of the hospital transparency rule and the transparency in coverage rule for health plans; and detail how the rules are impacting providers, payers, and consumers. Jackie, Maria, and Karen wrote an article about this topic for Health Law Connections magazine. From AHLA’s Regulation, Accreditation, and Payment Practice Group.
Watch this episode: https://www.youtube.com/watch?v=5cbxUKpklYQ
Read the article: https://www.americanhealthlaw.org/content-library/connections-magazine/article/f2560233-685a-4065-a989-d286ae43b2e6/Putting-Price-Transparency-into-Perspective
Learn more about AHLA’s Regulation, Accreditation, and Payment Practice Group: https://www.americanhealthlaw.org/practice-groups/practice-groups/regulation-accreditation-and-payment
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:00):
Hello, everyone.
My
SPEAKER_03 (00:18):
name is Jackie Selby.
I am here with Maria, Nicole,and Karen Mandelbaum, and we are
going to Do this podcast basedon price transparency rules.
We recently published an articlein Health Law Connections
magazine entitled Putting PriceTransparency into Perspective.
It covers both the hospitaltransparency rule and the
(00:41):
transparency and coverage rulefor health plans.
And by way of background, I'llintroduce myself and then I'll
pass it over to Maria.
I'm a partner at Epstein Beckerand Green for almost 20 years in
the healthcare practice.
Prior to that, I was in-housewith different large health
plans and I work mostly withproviders, but also health
(01:03):
plans.
I do work on the providercontracts with plans, drafting
and negotiation, as well asdispute resolution.
And I do a lot of value-basedpayment.
work.
So Maria, I'll turn it over toyou now.
SPEAKER_01 (01:18):
great thank you so much jackie and i'm so excited
to be here today my name ismarianna cole and i'm the ceo of
revelar analytics i've spent thelast 15 plus years in the
healthcare and operations andstrategy role mostly working on
partnering at various levels toaffect change in business
strategy working with largehealth plans as well as
(01:41):
providers and delving deeper anddeeper into the technology space
expertise in regulatory andcompliance issues, accountable
care organization developmentand operations, as well as
physician engagement.
And I've spent the last littlewhile working on informatics
analysis and the interpretationof large data sets, which
(02:04):
brought me over to RevelarAnalytics and helping to
decipher these extraordinarilylarge data sets.
And I'll pass it over to Karen.
SPEAKER_02 (02:13):
Thanks, Maria.
My name is Karen Mandelbaum andI'm a senior counsel at Epstein
Becker and Green.
I've been here for about sixyears and I work in the privacy,
cybersecurity and data assetmanagement group within the
firm.
I joined Epstein Becker from, Icame from CMS, from the Centers
for Medicare and MedicaidServices, where I was the
(02:36):
director of security and privacypolicy and an assistant to the
chief information officer.
Got a pretty close-up view ofthe development of the health
insurance marketplaces and alsoworked across the agency with
the different parts of CMS todeliver their data assets and to
(03:01):
manage their data.
And so had a unique opportunityto learn about the transparency
and coverage rules even beforethey were being written about in
regulations and being put out inrules.
So with that background, I'dlike to sort of dive right in to
(03:26):
why the transparency andcoverage rules are so important.
We all know that everyone atsome point in their lives need
doctors, nurses, hospitals.
And even when you have goodinsurance coverage, it can cost
a lot of money to get the carethat a person needs when an
(03:47):
illness strikes.
And too often, Too often we hearof stories where people actually
end up going bankrupt becausetheir healthcare costs so much.
And so really the only way toget our arms around this problem
is to know how much the carethat people need or that
(04:08):
individuals need is gonna costthem before they actually go to
the doctor or are admitted to ahospital.
And for a very long time, thatinformation wasn't available to
ordinary consumers before theyneeded the care that they had to
get.
And they would find out afterthey were discharged from a
(04:30):
hospital or a few weeks afterthey saw their doctor how much
the bill actually was going tocost them out of pocket.
Furthermore, for years,healthcare economists talked and
advocated about pricetransparency.
For as long as I can remember,they would say things like that
(04:54):
the rate of increases in thecost of healthcare were rising
in an unsustainable way.
Or they would say things likethe Medicare trust fund will run
out by a certain point in time.
And all the while, prices inhealthcare were continuing to
rise.
And they also became morecomplicated and more opaque.
(05:21):
And it was becoming harder andharder to figure out what the
cost of care actually was.
And so, you know, Now we havethese price transparency rules,
but there's quite a long historyof regulation in this space.
(05:41):
And I think that if we have toput a stake in the ground as to
when Congress actually startedto think about consumers in
healthcare and consumers havingan interest or needing to have
an interest in the cost and theprice of healthcare, it was in
2003 when when the MedicarePrescription Drug Improvement
(06:04):
and Modernization Act waspassed, that modified the IRS
code to pair a high deductiblehealth plan with a health
savings account, which gaveconsumers the ability to save
towards their healthcare costs.
They could sort of figure outwhere they were in their out of
(06:27):
pocket expenses and understandwhen the, insurance product that
they had purchased would kickin.
But up until that time, it gotpeople really thinking about
sort of like how much they werespending on health care.
And then it gave them theopportunity to save.
(06:48):
And it was their account.
A health savings account was notan account that was an
employer's account that just theemployer contributed money to,
but it was a savings accountthat the that the consumer or
that the employee or that thepatient had for themselves that
(07:09):
they could keep year over yearand was theirs to sort of have.
The Affordable Care Actintroduced the idea of
transparency, both for hospitalsand for health plans.
And so the first set of rulesthat was promulgated by CMS were
the hospital transparency rules.
(07:30):
Maria, you wanna talk a littlebit about the format of those
hospital transparency rules andtell us a little bit about what
your experience with those filesare?
SPEAKER_01 (07:42):
Yeah, absolutely.
So there's actually two rules,as Karen just alluded to.
One was for hospitals, and thatcame out around 21.
And basically, hospitals aresupposed to publish their
pricing information forconsumers to be able to see for
their top shoppable services.
That rule came out and thensubsequently another rule came
(08:05):
out similarly for health plansto be able to publish those same
files in a machine readableformat and that came out about a
year later in 2022 and soThere's various requirements,
both on the hospital side, aswell as on the health plan side,
in terms of how that informationis supposed to be available,
(08:25):
supposedly for consumers, but onthe health plan side, it's
definitely much more intricatethan that.
And we'll dive into that in justa little bit.
I wanted to pass it over toJackie, actually, to get us into
some of the background as well.
Jackie, what's been your kind ofexperience and take on that?
SPEAKER_03 (08:43):
I think both rules, the hospital rule and the plan
rule, do have information forboth consumers and vendors and
providers and such.
And although there's been noreal enforcement on the health
plan side, there have been noaudits, there can be penalties
(09:04):
that could be enforced up to$100a day, actually, per individual
and per violation.
So there could be significantpenalties on the plan side.
But on the hospital side, therehave actually been a number of
audits, maybe over 1,000.
And the hospital, there havebeen about 14 hospitals, I
(09:25):
believe, that have beenpenalized under civil monetary
penalties up to, I think it wasabout$4 million total.
So there has been some teeth.
But there's also been a recentexecutive order.
In February, the Trumpadministration issued an
executive order that requiresHHS to come up with additional
(09:47):
rules regarding pricetransparency that would increase
the enforcement of both rules.
The order mentioned thathospitals and plans really
haven't been held to account.
The order also requires HHS, Ithink by May 25th, about 90 days
after The order to requiredisclosures of actual prices,
(10:11):
and we'll get into what thatmeans, but not estimates.
Currently, at least the planrule only requires estimated
pricing information.
It would also require HHS torequire the information be
standardized, the pricinginformation be standardized.
And lastly, there was a hint ofpotentially expansion of the
(10:33):
rules to include newrequirements.
So stay tuned.
I'm sure we'll see more comingout of this administration on
these rules.
So I think we are going to alsomaybe talk about the impact or
the usefulness of the data toproviders.
(10:54):
Maria, do you want to?
SPEAKER_01 (10:57):
Yeah, absolutely.
Yeah.
So kind of going back to thesetwo rules, there's again, the
hospital rule that first cameout.
And as Jackie just said, there'sbeen very sparse enforcement on
that.
It's been really difficult toenforce these rules.
And on the hospital side, it'sjust the top shoppable services.
(11:17):
So if anybody has any interestin it, I encourage you to do so,
is go to a hospital website inyour area or your neighborhood
and see what that looks like.
And basically, right now, whatyou'll find is that each
hospital publishes these rulesin a variety of different
formats.
Some of them are searchabletools.
Others are Excel sheets.
(11:39):
Yet others are inmachine-readable formats.
And so I encourage everybody totry it I certainly did in the
very beginning just to see whatthe formats look like.
And again, it's the wild, wildwest of that.
And of course, each shoppableservice is just the top one.
So it's up to them to pick whichones they're going to disclose
and how they're going todisclose it.
(12:01):
And there's definitely not asingle unified schema for that.
So on the other side, on thehealth plan side, these files
are literally...
extraordinarily large and we'llget into some of the
difficulties around that but itdoes provide every single
service um that is negotiatedwith a potential provider and so
(12:21):
that's you know kind of ofinterest there um it's hundreds
of files super large uh they aremachine readable and thus not
human readable um and you knowwith that being said that
information um can be reallyuseful for provider
organizations as they're lookingto negotiate these payer
(12:44):
contracts, for example.
And that's just one use case ofthese machine-readable files.
It's really to understand whatthe fair market value looks
like.
However, there's definitely alot of challenges when you're
looking at literallymachine-readable files.
So what are they?
MRFs are extraordinarily large.
(13:05):
And so if a consumer, if youpretend that you're a consumer,
because I'm sure all of you areconsumers of healthcare, what
you'll do is you'll actually gointo a health plan.
You get really excited becausethere's a table of contents
that's there and you click thatdownload button.
But when you look at it, itmakes zero sense to the human
(13:26):
eye.
And what you really need is atechnical person and a process
to be able to work with thesefiles.
Now, Once you've parsed them,and maybe you can open up a
single file, what you'll find isthat these files are
extraordinarily large.
So a typical computer might noteven be able to open them.
So if you have a smallercapacity computer, you can't
(13:49):
open them.
For some of the smaller ones,you certainly will be able to.
But those rates are just singlevaried rates and they're usually
done by employer groups.
So the table of contents onlylists each information by an
employer group.
And so you don't have acomprehensive view of what.
(14:10):
these files actually mean it'slike finding a needle in a
haystack and you're like okay isee some really really
interesting information here andmaybe i could start to make out
what my competitor across thestreet might be reimbursed um
for these services but you don'tsee the entire scope in the
entire picture and you might noteven find uh your competitor in
(14:34):
each one of these files which isyou know very fascinating um but
when taken as a whole What youwill be able to do is make sense
of it.
So one of the other challengesthat I wanted to point out is
that in these machine-readablefiles, there's a CMS-approved
schema, which, again, ispublicly available.
You can see what the schema is.
(14:54):
And each health plan is expectedto comply with that rule.
Now, again, enforcement has beenvery sparse up until this point.
So what you actually see is thatit's not provided in a single
unified format.
So Oftentimes, what you'll endup seeing is these large, large
data sets, not in a singleunified schema.
(15:16):
And what really is important isto have a technology platform
that's able to decipher it andspit out a usable format for
those of you that are able towork with that data to then go
through and say, okay, I can nowgo through and use this for
contract negotiations.
So To that end, on thefee-for-service world, once
(15:40):
you're able to decipher andovercome some of these
challenges, and again, a datavendor and partner can certainly
help you with that, what you'llend up having is a really nice,
easily laid out format that laysout competitor X, Y, and Z, and
their ranges of what they getfor each of their billing codes.
(16:02):
So, you know, for example, anoffice visit, you'll see that
the range, you know, is between$50 and$150.
And now you know where yourclient falls into that range.
You can even pull that data outof these machine readable files.
And so let's say that yourclient is getting$100.
So they're not at the verybottom, they're not at the very
(16:22):
top, but you know, there'sanother$50 that might be able to
be had in that negotiation, youthen can come up with what fair
market value looks like, what'sthe average, and potentially use
this data for your contractnegotiation purposes to say, you
know what, I'm really notgetting what others are getting
(16:42):
in my area.
And so what we see is typicallyabout a 3x variation.
in rates across any specificgeographic area.
Literally, somebody across thestreet might be getting
significantly more than you forevery single procedure and every
single billing code within, I'mgoing to say, the same taxonomy.
(17:03):
So cardiologist compared to acardiologist, a nephrologist
compared to a nephrologist,etc., etc.
Interestingly, some of the workthat we've done Especially for
large hospital systems, forexample, there's definitely not
uniformity to that.
So even, I mean, size doesmatter in this instance.
(17:24):
And so larger systems typicallyhave higher reimbursement
values, which probably isn't asurprise to anybody.
However, within that, there'sdefinitely still variation and
significant variation, whichamounts to millions of dollars a
year in potential revenue interms of negotiations.
And as health plans are lookingto negotiate that, both on the
(17:47):
health plan side and theprovider side, it's really
important to understand whatthat landscape looks like and
what those in your area arebeing reimbursed.
And so fee for service reallymakes sense as you start to
delve into value-based careagreements.
That information is reallyhelpful as well.
Because bundled payments are inthere, capitated rates are in
(18:11):
there as well, so you can startto make out what that looks
like.
And additionally, you couldstart to figure out your own...
ideas around which bundle youmight want to create and where
your reimbursement patterns looklike.
That's some of the much morenovel approaches on price
transparency that we've beenworking on, actually.
(18:32):
Super cutting edge stuff.
And then in the development ofpreferred provider networks.
So, you know, do you want tosend your patients to the
highest value provider?
So not necessarily somebodythat's charging less or somebody
that's charging more, but reallylooking at cost and quality
information as you can start toto add in quality metrics in
(18:53):
addition to cost to some of thisdata, which is really, really
interesting.
And then on the provider disputeside and the payer dispute side,
and especially forout-of-network contracts, this
data is super interesting.
So the out-of-network files arealso available.
So there's three types of files,the in-network and the
(19:15):
out-of-network files that arewithin these data sets.
And so you can start to delveinto out-of-network providers
and what are those paymentslooking like.
And then, so that's really onthe provider side in terms of
contract negotiations.
But again, it's really importantto be able to get your hands on
the data, make sense of the databefore you embark on the journey
(19:39):
of engaging in a contractnegotiation.
What I think a big challenge is,and again, because this data is
so large, so complex, there'sthousands of files that are then
updated as frequently asmonthly.
What you don't want to be doingis kind of running that hamster
wheel of to be able to look atthis data.
(20:01):
Once you get those actionableinsights, then you can actually
take that for a contractnegotiation, a payer dispute, et
cetera.
So Jackie, can you tell us alittle bit more about the
usefulness of this data on theconsumer side?
SPEAKER_03 (20:17):
Absolutely.
But I do have one question, ifyou don't mind.
I'm curious, in thesenegotiations, since providers
can see their competitors'rates, plans also see their
competitors' rates.
So in your experience, maybeit's too early, do we have a
sense of whether prices mightactually be going down since
(20:38):
plans see the discounts thatprovider gives to their
competitor?
They're looking for lower ratesand the provider, of course, is
comparing themselves to theircompetitors and looking for
higher rates.
So net net, do we have a senseof the impact?
SPEAKER_01 (20:54):
Yeah.
I would say it's too early totell.
Yes, I think ultimately, if Ihad a crystal ball, we're going
to see some sort of culminationtowards center in the middle
ground.
Because again, what we're seeingright now is about a 3x
variation, which is huge,obviously resulting in
significant revenue on bothsides of the aisle, obviously.
(21:16):
And so, yeah, as you start tohave payers pulling this
information, providers pullingthis information, everybody has
kind of a level playing field,if you will.
So crystal ball, yeah, we'll seea culmination towards center,
perhaps.
Again, we haven't seen that playout yet.
In fact, I would say both sidesare still surprised of how did
(21:40):
you get that information?
I didn't know that that'spublicly available.
How are you not violating theseantitrust laws?
Well, it's public.
It's on your website.
You know, so it's definitelyinteresting.
You know, and start to have aculmination towards center
perhaps and that's where we aregoing to hopefully see um again
(22:01):
the the evolution of value-basedcare um and using additional
quality metrics um novel paymentarrangements um that hopefully
will end up bringing costs downand increase quality of care for
patients really that's that'swhat my hope is um not that
(22:23):
we're in this fee-for-serviceand, hey, I need a dollar more
for each service.
But really, hopefully, this willultimately benefit the consumer
in that we all end up withhigher quality care and
hopefully providers arereimbursed a fair market value
for their services and they'reable to keep their doors open
(22:44):
and they feel safe.
because I know that that's alsothis metric that's been going
down as well as that providersatisfaction in their day-to-day
work as they're encouraged to domore and more in the
fee-for-service world.
So
SPEAKER_02 (23:00):
just to jump in here for a second to answer your
question, Maria, about theconsumer side, we're talking a
lot about the providers and thepayers.
But one of the nuances in thetransparency and coverage rules
was that employers as thesponsors of group health plans
(23:23):
were also considered anddiscussed by the three agencies
that put these rules out, theIRS, the Department of Labor,
and CMS, that group health plansalso play a very big role in
designing their their plans fortheir employees and employees
(23:44):
are, and then again, there isthe consumer, there is the
patient.
And so both the transparency andcoverage rules and the hospital
transparency rules have arequirement that some sort of
tool be developed that takethese very undigestible tools
(24:06):
files that are machine readableand turn it into real
information for patients and forthe individual.
And so, like you said earlier,like, you know, we do encourage
people to use those tools thatare on hospital websites.
(24:27):
And then you can do it in yourown, with your own insurance
product.
You should have, there should bea tool that you can enter your
name and your group number andyour insurance information into
that will, and then you canrequest like, you know, a CPT
code and that information thatthat information from the
(24:52):
machine readable file will besynthesized it'll be
personalized too and it'll letyou know what you as a consumer,
what your out-of-pocket costsare.
So as useful and as helpful asthis information can be in
negotiations, in fair marketvaluations, in acquisitions of
(25:16):
providers and of provider groupsand organizations, as important
as it is for those purposes andas useful as it is, also really
super important for employers tounderstand and to be used by
employees as well.
We're seeing that withemployers, they don't really
(25:41):
understand it.
We work with group health plansand with employers that sponsor
group health plans, and they'renot sure what the data is, what
value the data has.
oftentimes they're reticent toengage with it.
(26:03):
That's the information that canreally help them decide on how
to design their health plan,what's happening with their
benefit structure.
A lot of times, TPAs and PBMsdon't give group health plans
(26:24):
access to the claims data thatcomes through on a real time
sort of basis, it's difficultsometimes for those group health
plans to really understand whatthe cost of care is.
And if they use their ownmachine readable files, they
would find that they have a lotmore information at their
(26:46):
fingertips and they could helpthemselves lower the lower their
costs.
They could make choices like,for instance, to try to get into
the direct provider contractingsort of mode if certain services
are costing more than theyanticipate or more than they
(27:10):
want.
There are those types ofstrategic ways that employers
can also, as consumers ofhealthcare, use those files to
their best advantage.
And I'll just add one lastthing.
One of the reasons that thegroup health plans didn't really
sort of have the opportunity tocut their teeth and to learn
(27:32):
about those machine readablefiles is because they don't have
access to their claims data.
Because the TPAs and theinsurance companies that either,
if either they're self-insured,they'll use a TPA, whether fully
insured, they'll have aninsurance plan.
What the insurance companies didto sort of ensure that they had
(27:53):
a little more control over thesefiles was they took the
initiative to sort of step in.
And they said, don't worryabout, you know, to their group
health plan customers, theysaid, don't worry about
publishing those files.
We'll do it for you.
And we'll post it, and we allhave a link, and it's on their
(28:17):
site.
Now, the group health plansstill need to have it on their
site that's publicly available,which is sometimes a challenge
to figure out.
But as a general rule, theposting is right on the
insurance company or the TPA'swebsite, and that's provided to
the to the group health plan tobe able to publish.
(28:40):
So it was kind of like theinsurance companies have all
that data.
So they've done this the waythey sort of want it.
It's in the format that theywant.
I know, and Maria, you couldtalk a little bit more about
this also.
We've mentioned the complexity.
I think that in the rules, theformats, that schema that you
(29:05):
were describing, there were, Ithink, six different
machine-readable languages thatCMS and DOL and the Treasury
said that could be used.
I think that what we're seeingis that the most complicated
one, JSON, was the one that mostof the insurance companies
(29:27):
actually chose.
So it actually does requiresomebody that really has
experience with that kind ofcomputer language and really
strong skills in programming.
So it's really a tough languageto deal with.
SPEAKER_01 (29:45):
Yeah, these are definitely JSON files from our
experience, especially for, youknow, the really large payers.
The smaller ones we've seensignificantly less compliance
with in posting anything at allor, you know, you'll go to the
website and it just totallycrashes.
Not your computer crashing, butliterally it's like unavailable.
We'll get back to you in sixmonths.
(30:08):
So but yeah, these files aregreat.
really listed by the employer,back to what Karen was just
saying, and by employer group.
And that's what results inliterally thousands of files
that then need to be, again, ifyou don't have a machine to open
it and somebody to searchexactly what file you're looking
for, you would literally have toopen thousands of files on a
(30:32):
monthly basis to try to find theone that you're looking for
maybe.
And maybe you're looking for 10of them out of thousands, so
there's no way to actually findit.
Now, one of the other datacomplexities is the way that
things are billed andunderstanding what NPI intend to
utilize to be able to then pullthat file.
(30:55):
Anyway, everybody's familiarwith hospital systems.
Let's take a hospital system asthe example.
they're going to use multipleTINs and NPIs to be able to bill
under that.
And so those rates, you don'tknow which one of the hundreds,
literally, that they have thattheir rates are under.
So you need to be able tounderstand that part of the
equation before you even startto do the data pull.
(31:17):
and you think you have their TINand you think you might have
their NPI, and then you gosearch that file and what you
come up with is nothing.
And so it's really important tobe able to holistically look at
all of the rates under all ofthe TINs and NPIs for a specific
system to be able to pull underthat, especially with mergers,
(31:37):
acquisitions going on.
You can't just pull on a name.
You have to be able to identifythe specific TIN and NPI by
which you then do the pull Whichpresents another data complexity
and challenge that we kind ofhaven't covered.
Again, across multiple,literally thousands of files.
(31:58):
So now you're searching forhundreds of NPIs across
thousands of files, which again,not very human friendly.
Yeah.
And to that effect, that's notjust for hospital systems.
That's also for largerpractices, MSOs, IPAs.
You need to be able toholistically pull their
(32:18):
information.
The hospital system was just asmall example of that.
SPEAKER_03 (32:24):
So I would like to just circle back for a minute on
the fact that the patient thatis looking, shopping for
healthcare services and lookingat this data on the website, say
of their plan, there's no app,by the way, that was deemed to
be too burdensome at this time.
So they go to, an individualgoes to the plan website and
(32:47):
what they're going to get, acouple limitations on that data,
they're going to get anestimate.
And again, the exact executiveorder is looking to change that
and possibly include actualpricing information, not
estimates, but it'll be veryinteresting because the plans
don't likely have enoughinformation to commit to what
(33:08):
the price is in advance.
They'll get the code.
You have to put in the CPT code.
You have to get that from yourprovider and put that in the
insurance plan's website.
But coverage is a verycomplicated concept.
And so whether they would committhat they would pay that price
depends in part on whether theyview it as a covered service or
(33:31):
not.
And that might include, forexample, a medical necessity
review of whether the service isrequired.
So I'm not exactly sure what theactual prices mentioned in the
executive order will look like,but it'll be interesting to
follow.
And then one last point on thepatient data.
Remember, there's no qualitydata.
This is all cost information.
(33:53):
And so you're going to have togo to other places for that
quality data.
Perhaps CMS website has someinformation on quality for
hospitals, at least.
And so that's a piece of the theshopping experience, right?
Is you wanna pick a qualityprovider.
So this is all about cost.
So we really are at thebeginning stages, but in the
(34:14):
shopping experience, justunderstand.
And the last thing, actually,one other thing I thought of
was, if you're interested ingoing out of network, the data
is limited in that sense.
You'll get the allowed amountthat the plan is willing to pay,
which is not what you will bebilled by the provider.
So if you're going out innetwork, there's a high chance
(34:36):
that that allowed amount won'tcover the provider's full billed
amount.
And so that difference would bebalanced billed to you.
So you would have to go back tothe provider and get that data
from that provider.
So you as the patient have to doa lot of work pulling together
the provider and the plan, theproviders and the plans don't
have to work together to get youthis data.
(34:59):
So it's, it's, It's complicated.
I'll end on that note.
Do you guys have any otherspecific uses or limitations of
the data that you wanted toaddress that we didn't hit on?
No, I
SPEAKER_02 (35:16):
think that what your observation, your observations,
Jackie, are very on point, youknow, and really, you know,
rather than view it as sort of athis is just gonna be more
confusing or create moreconfusion.
I think looking at this as thefirst step and it's a small step
(35:41):
in the right direction that willeventually work together with
the other forces.
So a lot of times we have atendency to focus on one area,
The Affordable Care Act was amassive law and it has lots of
(36:05):
moving pieces.
There have been other componentsand other laws that have passed
things like MACRA with theQuality Payments Program, the
21st Century Cures Act, andthose types of laws that have
brought more clarity to wherethe transparency and coverage
rules need to go and thehospital transparency rules need
(36:28):
to go.
And so just keeping in mind thatit took us probably half a
century to get to the pointwhere we said, oh boy, We need
this clarified, and it's notgoing to get unwound with one
set of rules.
And again, transparency alsomeans something a little bit
(36:51):
different to each of thestakeholders in this whole
paradigm.
what transparency means to anindividual patient is something
very different than whattransparency means to a health
plan, to an insurer, to aprovider, and within the
(37:12):
provider organizations, there'sa lot of variation between
medical practice groups andhospital groups and health
centers and all those types ofthings.
So just keeping in mind thatthis is the first step,
giving...
We should give it a chance.
We shouldn't get too frustratedby it.
(37:33):
And enforcement isn'tnecessarily a bad thing, but we
have to remember that it costs alot to enforce.
And so it's really looking atthe ways that everyone can
benefit from the right pathforward here.
Well said.
SPEAKER_01 (37:53):
Yeah, absolutely.
Just to add a little bit more tothat, I think you're right.
This is just the first ofhopefully many steps towards
increasing price transparency.
And again, the large payers byand far are fairly compliant, at
least posting some reallycritical pricing information.
And again, our clients have usedthis information for contract
negotiations extraordinarilysuccessfully.
(38:16):
And while there's so muchcomplexity to it, it's really
good.
But then there's other...
non-compliance issues as youdelve deeper and deeper into it.
And, you know, some rates arenot published, some procedures
are not published.
So, you know, if you're lookingfor a very specific thing, it
might not be in there, or aspecific group might not be in
(38:37):
there.
So like an omission of a largehospital system that you know
exists.
And, you know, if you compare,interestingly, the hospital file
and the health plan file, whatdo you come up with there?
Sometimes some pricingvariation.
Sometimes you see that thehospital posted that information
while the health plan didn't.
(38:58):
So that's of interest.
But again, as we go further andfurther, hopefully there's more
compliance, more enforcement.
But by and large, thisinformation is extremely helpful
and it's a great first step, asKaren said.
So I absolutely echo and agreewith that.
SPEAKER_03 (39:16):
Lots
SPEAKER_01 (39:16):
to come.
SPEAKER_02 (39:17):
Yeah.
Well, it was great talking toboth of you today about this.
SPEAKER_01 (39:22):
Same.
Yeah, this
SPEAKER_00 (39:24):
is fun.
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(39:45):
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you
Hello, everyone.
My
SPEAKER_03 (00:18):
name is Jackie Selby.
I am here with Maria, Nicole,and Karen Mandelbaum, and we are
going to Do this podcast basedon price transparency rules.
We recently published an articlein Health Law Connections
magazine entitled Putting PriceTransparency into Perspective.
It covers both the hospitaltransparency rule and the
(00:41):
transparency and coverage rulefor health plans.
And by way of background, I'llintroduce myself and then I'll
pass it over to Maria.
I'm a partner at Epstein Beckerand Green for almost 20 years in
the healthcare practice.
Prior to that, I was in-housewith different large health
plans and I work mostly withproviders, but also health
(01:03):
plans.
I do work on the providercontracts with plans, drafting
and negotiation, as well asdispute resolution.
And I do a lot of value-basedpayment.
work.
So Maria, I'll turn it over toyou now.
SPEAKER_01 (01:18):
great thank you so much jackie and i'm so excited
to be here today my name ismarianna cole and i'm the ceo of
revelar analytics i've spent thelast 15 plus years in the
healthcare and operations andstrategy role mostly working on
partnering at various levels toaffect change in business
strategy working with largehealth plans as well as
(01:41):
providers and delving deeper anddeeper into the technology space
expertise in regulatory andcompliance issues, accountable
care organization developmentand operations, as well as
physician engagement.
And I've spent the last littlewhile working on informatics
analysis and the interpretationof large data sets, which
(02:04):
brought me over to RevelarAnalytics and helping to
decipher these extraordinarilylarge data sets.
And I'll pass it over to Karen.
SPEAKER_02 (02:13):
Thanks, Maria.
My name is Karen Mandelbaum andI'm a senior counsel at Epstein
Becker and Green.
I've been here for about sixyears and I work in the privacy,
cybersecurity and data assetmanagement group within the
firm.
I joined Epstein Becker from, Icame from CMS, from the Centers
for Medicare and MedicaidServices, where I was the
(02:36):
director of security and privacypolicy and an assistant to the
chief information officer.
Got a pretty close-up view ofthe development of the health
insurance marketplaces and alsoworked across the agency with
the different parts of CMS todeliver their data assets and to
(03:01):
manage their data.
And so had a unique opportunityto learn about the transparency
and coverage rules even beforethey were being written about in
regulations and being put out inrules.
So with that background, I'dlike to sort of dive right in to
(03:26):
why the transparency andcoverage rules are so important.
We all know that everyone atsome point in their lives need
doctors, nurses, hospitals.
And even when you have goodinsurance coverage, it can cost
a lot of money to get the carethat a person needs when an
(03:47):
illness strikes.
And too often, Too often we hearof stories where people actually
end up going bankrupt becausetheir healthcare costs so much.
And so really the only way toget our arms around this problem
is to know how much the carethat people need or that
(04:08):
individuals need is gonna costthem before they actually go to
the doctor or are admitted to ahospital.
And for a very long time, thatinformation wasn't available to
ordinary consumers before theyneeded the care that they had to
get.
And they would find out afterthey were discharged from a
(04:30):
hospital or a few weeks afterthey saw their doctor how much
the bill actually was going tocost them out of pocket.
Furthermore, for years,healthcare economists talked and
advocated about pricetransparency.
For as long as I can remember,they would say things like that
(04:54):
the rate of increases in thecost of healthcare were rising
in an unsustainable way.
Or they would say things likethe Medicare trust fund will run
out by a certain point in time.
And all the while, prices inhealthcare were continuing to
rise.
And they also became morecomplicated and more opaque.
(05:21):
And it was becoming harder andharder to figure out what the
cost of care actually was.
And so, you know, Now we havethese price transparency rules,
but there's quite a long historyof regulation in this space.
(05:41):
And I think that if we have toput a stake in the ground as to
when Congress actually startedto think about consumers in
healthcare and consumers havingan interest or needing to have
an interest in the cost and theprice of healthcare, it was in
2003 when when the MedicarePrescription Drug Improvement
(06:04):
and Modernization Act waspassed, that modified the IRS
code to pair a high deductiblehealth plan with a health
savings account, which gaveconsumers the ability to save
towards their healthcare costs.
They could sort of figure outwhere they were in their out of
(06:27):
pocket expenses and understandwhen the, insurance product that
they had purchased would kickin.
But up until that time, it gotpeople really thinking about
sort of like how much they werespending on health care.
And then it gave them theopportunity to save.
(06:48):
And it was their account.
A health savings account was notan account that was an
employer's account that just theemployer contributed money to,
but it was a savings accountthat the that the consumer or
that the employee or that thepatient had for themselves that
(07:09):
they could keep year over yearand was theirs to sort of have.
The Affordable Care Actintroduced the idea of
transparency, both for hospitalsand for health plans.
And so the first set of rulesthat was promulgated by CMS were
the hospital transparency rules.
(07:30):
Maria, you wanna talk a littlebit about the format of those
hospital transparency rules andtell us a little bit about what
your experience with those filesare?
SPEAKER_01 (07:42):
Yeah, absolutely.
So there's actually two rules,as Karen just alluded to.
One was for hospitals, and thatcame out around 21.
And basically, hospitals aresupposed to publish their
pricing information forconsumers to be able to see for
their top shoppable services.
That rule came out and thensubsequently another rule came
(08:05):
out similarly for health plansto be able to publish those same
files in a machine readableformat and that came out about a
year later in 2022 and soThere's various requirements,
both on the hospital side, aswell as on the health plan side,
in terms of how that informationis supposed to be available,
(08:25):
supposedly for consumers, but onthe health plan side, it's
definitely much more intricatethan that.
And we'll dive into that in justa little bit.
I wanted to pass it over toJackie, actually, to get us into
some of the background as well.
Jackie, what's been your kind ofexperience and take on that?
SPEAKER_03 (08:43):
I think both rules, the hospital rule and the plan
rule, do have information forboth consumers and vendors and
providers and such.
And although there's been noreal enforcement on the health
plan side, there have been noaudits, there can be penalties
(09:04):
that could be enforced up to$100a day, actually, per individual
and per violation.
So there could be significantpenalties on the plan side.
But on the hospital side, therehave actually been a number of
audits, maybe over 1,000.
And the hospital, there havebeen about 14 hospitals, I
(09:25):
believe, that have beenpenalized under civil monetary
penalties up to, I think it wasabout$4 million total.
So there has been some teeth.
But there's also been a recentexecutive order.
In February, the Trumpadministration issued an
executive order that requiresHHS to come up with additional
(09:47):
rules regarding pricetransparency that would increase
the enforcement of both rules.
The order mentioned thathospitals and plans really
haven't been held to account.
The order also requires HHS, Ithink by May 25th, about 90 days
after The order to requiredisclosures of actual prices,
(10:11):
and we'll get into what thatmeans, but not estimates.
Currently, at least the planrule only requires estimated
pricing information.
It would also require HHS torequire the information be
standardized, the pricinginformation be standardized.
And lastly, there was a hint ofpotentially expansion of the
(10:33):
rules to include newrequirements.
So stay tuned.
I'm sure we'll see more comingout of this administration on
these rules.
So I think we are going to alsomaybe talk about the impact or
the usefulness of the data toproviders.
(10:54):
Maria, do you want to?
SPEAKER_01 (10:57):
Yeah, absolutely.
Yeah.
So kind of going back to thesetwo rules, there's again, the
hospital rule that first cameout.
And as Jackie just said, there'sbeen very sparse enforcement on
that.
It's been really difficult toenforce these rules.
And on the hospital side, it'sjust the top shoppable services.
(11:17):
So if anybody has any interestin it, I encourage you to do so,
is go to a hospital website inyour area or your neighborhood
and see what that looks like.
And basically, right now, whatyou'll find is that each
hospital publishes these rulesin a variety of different
formats.
Some of them are searchabletools.
Others are Excel sheets.
(11:39):
Yet others are inmachine-readable formats.
And so I encourage everybody totry it I certainly did in the
very beginning just to see whatthe formats look like.
And again, it's the wild, wildwest of that.
And of course, each shoppableservice is just the top one.
So it's up to them to pick whichones they're going to disclose
and how they're going todisclose it.
(12:01):
And there's definitely not asingle unified schema for that.
So on the other side, on thehealth plan side, these files
are literally...
extraordinarily large and we'llget into some of the
difficulties around that but itdoes provide every single
service um that is negotiatedwith a potential provider and so
(12:21):
that's you know kind of ofinterest there um it's hundreds
of files super large uh they aremachine readable and thus not
human readable um and you knowwith that being said that
information um can be reallyuseful for provider
organizations as they're lookingto negotiate these payer
(12:44):
contracts, for example.
And that's just one use case ofthese machine-readable files.
It's really to understand whatthe fair market value looks
like.
However, there's definitely alot of challenges when you're
looking at literallymachine-readable files.
So what are they?
MRFs are extraordinarily large.
(13:05):
And so if a consumer, if youpretend that you're a consumer,
because I'm sure all of you areconsumers of healthcare, what
you'll do is you'll actually gointo a health plan.
You get really excited becausethere's a table of contents
that's there and you click thatdownload button.
But when you look at it, itmakes zero sense to the human
(13:26):
eye.
And what you really need is atechnical person and a process
to be able to work with thesefiles.
Now, Once you've parsed them,and maybe you can open up a
single file, what you'll find isthat these files are
extraordinarily large.
So a typical computer might noteven be able to open them.
So if you have a smallercapacity computer, you can't
(13:49):
open them.
For some of the smaller ones,you certainly will be able to.
But those rates are just singlevaried rates and they're usually
done by employer groups.
So the table of contents onlylists each information by an
employer group.
And so you don't have acomprehensive view of what.
(14:10):
these files actually mean it'slike finding a needle in a
haystack and you're like okay isee some really really
interesting information here andmaybe i could start to make out
what my competitor across thestreet might be reimbursed um
for these services but you don'tsee the entire scope in the
entire picture and you might noteven find uh your competitor in
(14:34):
each one of these files which isyou know very fascinating um but
when taken as a whole What youwill be able to do is make sense
of it.
So one of the other challengesthat I wanted to point out is
that in these machine-readablefiles, there's a CMS-approved
schema, which, again, ispublicly available.
You can see what the schema is.
(14:54):
And each health plan is expectedto comply with that rule.
Now, again, enforcement has beenvery sparse up until this point.
So what you actually see is thatit's not provided in a single
unified format.
So Oftentimes, what you'll endup seeing is these large, large
data sets, not in a singleunified schema.
(15:16):
And what really is important isto have a technology platform
that's able to decipher it andspit out a usable format for
those of you that are able towork with that data to then go
through and say, okay, I can nowgo through and use this for
contract negotiations.
So To that end, on thefee-for-service world, once
(15:40):
you're able to decipher andovercome some of these
challenges, and again, a datavendor and partner can certainly
help you with that, what you'llend up having is a really nice,
easily laid out format that laysout competitor X, Y, and Z, and
their ranges of what they getfor each of their billing codes.
(16:02):
So, you know, for example, anoffice visit, you'll see that
the range, you know, is between$50 and$150.
And now you know where yourclient falls into that range.
You can even pull that data outof these machine readable files.
And so let's say that yourclient is getting$100.
So they're not at the verybottom, they're not at the very
(16:22):
top, but you know, there'sanother$50 that might be able to
be had in that negotiation, youthen can come up with what fair
market value looks like, what'sthe average, and potentially use
this data for your contractnegotiation purposes to say, you
know what, I'm really notgetting what others are getting
(16:42):
in my area.
And so what we see is typicallyabout a 3x variation.
in rates across any specificgeographic area.
Literally, somebody across thestreet might be getting
significantly more than you forevery single procedure and every
single billing code within, I'mgoing to say, the same taxonomy.
(17:03):
So cardiologist compared to acardiologist, a nephrologist
compared to a nephrologist,etc., etc.
Interestingly, some of the workthat we've done Especially for
large hospital systems, forexample, there's definitely not
uniformity to that.
So even, I mean, size doesmatter in this instance.
(17:24):
And so larger systems typicallyhave higher reimbursement
values, which probably isn't asurprise to anybody.
However, within that, there'sdefinitely still variation and
significant variation, whichamounts to millions of dollars a
year in potential revenue interms of negotiations.
And as health plans are lookingto negotiate that, both on the
(17:47):
health plan side and theprovider side, it's really
important to understand whatthat landscape looks like and
what those in your area arebeing reimbursed.
And so fee for service reallymakes sense as you start to
delve into value-based careagreements.
That information is reallyhelpful as well.
Because bundled payments are inthere, capitated rates are in
(18:11):
there as well, so you can startto make out what that looks
like.
And additionally, you couldstart to figure out your own...
ideas around which bundle youmight want to create and where
your reimbursement patterns looklike.
That's some of the much morenovel approaches on price
transparency that we've beenworking on, actually.
(18:32):
Super cutting edge stuff.
And then in the development ofpreferred provider networks.
So, you know, do you want tosend your patients to the
highest value provider?
So not necessarily somebodythat's charging less or somebody
that's charging more, but reallylooking at cost and quality
information as you can start toto add in quality metrics in
(18:53):
addition to cost to some of thisdata, which is really, really
interesting.
And then on the provider disputeside and the payer dispute side,
and especially forout-of-network contracts, this
data is super interesting.
So the out-of-network files arealso available.
So there's three types of files,the in-network and the
(19:15):
out-of-network files that arewithin these data sets.
And so you can start to delveinto out-of-network providers
and what are those paymentslooking like.
And then, so that's really onthe provider side in terms of
contract negotiations.
But again, it's really importantto be able to get your hands on
the data, make sense of the databefore you embark on the journey
(19:39):
of engaging in a contractnegotiation.
What I think a big challenge is,and again, because this data is
so large, so complex, there'sthousands of files that are then
updated as frequently asmonthly.
What you don't want to be doingis kind of running that hamster
wheel of to be able to look atthis data.
(20:01):
Once you get those actionableinsights, then you can actually
take that for a contractnegotiation, a payer dispute, et
cetera.
So Jackie, can you tell us alittle bit more about the
usefulness of this data on theconsumer side?
SPEAKER_03 (20:17):
Absolutely.
But I do have one question, ifyou don't mind.
I'm curious, in thesenegotiations, since providers
can see their competitors'rates, plans also see their
competitors' rates.
So in your experience, maybeit's too early, do we have a
sense of whether prices mightactually be going down since
(20:38):
plans see the discounts thatprovider gives to their
competitor?
They're looking for lower ratesand the provider, of course, is
comparing themselves to theircompetitors and looking for
higher rates.
So net net, do we have a senseof the impact?
SPEAKER_01 (20:54):
Yeah.
I would say it's too early totell.
Yes, I think ultimately, if Ihad a crystal ball, we're going
to see some sort of culminationtowards center in the middle
ground.
Because again, what we're seeingright now is about a 3x
variation, which is huge,obviously resulting in
significant revenue on bothsides of the aisle, obviously.
(21:16):
And so, yeah, as you start tohave payers pulling this
information, providers pullingthis information, everybody has
kind of a level playing field,if you will.
So crystal ball, yeah, we'll seea culmination towards center,
perhaps.
Again, we haven't seen that playout yet.
In fact, I would say both sidesare still surprised of how did
(21:40):
you get that information?
I didn't know that that'spublicly available.
How are you not violating theseantitrust laws?
Well, it's public.
It's on your website.
You know, so it's definitelyinteresting.
You know, and start to have aculmination towards center
perhaps and that's where we aregoing to hopefully see um again
(22:01):
the the evolution of value-basedcare um and using additional
quality metrics um novel paymentarrangements um that hopefully
will end up bringing costs downand increase quality of care for
patients really that's that'swhat my hope is um not that
(22:23):
we're in this fee-for-serviceand, hey, I need a dollar more
for each service.
But really, hopefully, this willultimately benefit the consumer
in that we all end up withhigher quality care and
hopefully providers arereimbursed a fair market value
for their services and they'reable to keep their doors open
(22:44):
and they feel safe.
because I know that that's alsothis metric that's been going
down as well as that providersatisfaction in their day-to-day
work as they're encouraged to domore and more in the
fee-for-service world.
So
SPEAKER_02 (23:00):
just to jump in here for a second to answer your
question, Maria, about theconsumer side, we're talking a
lot about the providers and thepayers.
But one of the nuances in thetransparency and coverage rules
was that employers as thesponsors of group health plans
(23:23):
were also considered anddiscussed by the three agencies
that put these rules out, theIRS, the Department of Labor,
and CMS, that group health plansalso play a very big role in
designing their their plans fortheir employees and employees
(23:44):
are, and then again, there isthe consumer, there is the
patient.
And so both the transparency andcoverage rules and the hospital
transparency rules have arequirement that some sort of
tool be developed that takethese very undigestible tools
(24:06):
files that are machine readableand turn it into real
information for patients and forthe individual.
And so, like you said earlier,like, you know, we do encourage
people to use those tools thatare on hospital websites.
(24:27):
And then you can do it in yourown, with your own insurance
product.
You should have, there should bea tool that you can enter your
name and your group number andyour insurance information into
that will, and then you canrequest like, you know, a CPT
code and that information thatthat information from the
(24:52):
machine readable file will besynthesized it'll be
personalized too and it'll letyou know what you as a consumer,
what your out-of-pocket costsare.
So as useful and as helpful asthis information can be in
negotiations, in fair marketvaluations, in acquisitions of
(25:16):
providers and of provider groupsand organizations, as important
as it is for those purposes andas useful as it is, also really
super important for employers tounderstand and to be used by
employees as well.
We're seeing that withemployers, they don't really
(25:41):
understand it.
We work with group health plansand with employers that sponsor
group health plans, and they'renot sure what the data is, what
value the data has.
oftentimes they're reticent toengage with it.
(26:03):
That's the information that canreally help them decide on how
to design their health plan,what's happening with their
benefit structure.
A lot of times, TPAs and PBMsdon't give group health plans
(26:24):
access to the claims data thatcomes through on a real time
sort of basis, it's difficultsometimes for those group health
plans to really understand whatthe cost of care is.
And if they use their ownmachine readable files, they
would find that they have a lotmore information at their
(26:46):
fingertips and they could helpthemselves lower the lower their
costs.
They could make choices like,for instance, to try to get into
the direct provider contractingsort of mode if certain services
are costing more than theyanticipate or more than they
(27:10):
want.
There are those types ofstrategic ways that employers
can also, as consumers ofhealthcare, use those files to
their best advantage.
And I'll just add one lastthing.
One of the reasons that thegroup health plans didn't really
sort of have the opportunity tocut their teeth and to learn
(27:32):
about those machine readablefiles is because they don't have
access to their claims data.
Because the TPAs and theinsurance companies that either,
if either they're self-insured,they'll use a TPA, whether fully
insured, they'll have aninsurance plan.
What the insurance companies didto sort of ensure that they had
(27:53):
a little more control over thesefiles was they took the
initiative to sort of step in.
And they said, don't worryabout, you know, to their group
health plan customers, theysaid, don't worry about
publishing those files.
We'll do it for you.
And we'll post it, and we allhave a link, and it's on their
(28:17):
site.
Now, the group health plansstill need to have it on their
site that's publicly available,which is sometimes a challenge
to figure out.
But as a general rule, theposting is right on the
insurance company or the TPA'swebsite, and that's provided to
the to the group health plan tobe able to publish.
(28:40):
So it was kind of like theinsurance companies have all
that data.
So they've done this the waythey sort of want it.
It's in the format that theywant.
I know, and Maria, you couldtalk a little bit more about
this also.
We've mentioned the complexity.
I think that in the rules, theformats, that schema that you
(29:05):
were describing, there were, Ithink, six different
machine-readable languages thatCMS and DOL and the Treasury
said that could be used.
I think that what we're seeingis that the most complicated
one, JSON, was the one that mostof the insurance companies
(29:27):
actually chose.
So it actually does requiresomebody that really has
experience with that kind ofcomputer language and really
strong skills in programming.
So it's really a tough languageto deal with.
SPEAKER_01 (29:45):
Yeah, these are definitely JSON files from our
experience, especially for, youknow, the really large payers.
The smaller ones we've seensignificantly less compliance
with in posting anything at allor, you know, you'll go to the
website and it just totallycrashes.
Not your computer crashing, butliterally it's like unavailable.
We'll get back to you in sixmonths.
(30:08):
So but yeah, these files aregreat.
really listed by the employer,back to what Karen was just
saying, and by employer group.
And that's what results inliterally thousands of files
that then need to be, again, ifyou don't have a machine to open
it and somebody to searchexactly what file you're looking
for, you would literally have toopen thousands of files on a
(30:32):
monthly basis to try to find theone that you're looking for
maybe.
And maybe you're looking for 10of them out of thousands, so
there's no way to actually findit.
Now, one of the other datacomplexities is the way that
things are billed andunderstanding what NPI intend to
utilize to be able to then pullthat file.
(30:55):
Anyway, everybody's familiarwith hospital systems.
Let's take a hospital system asthe example.
they're going to use multipleTINs and NPIs to be able to bill
under that.
And so those rates, you don'tknow which one of the hundreds,
literally, that they have thattheir rates are under.
So you need to be able tounderstand that part of the
equation before you even startto do the data pull.
(31:17):
and you think you have their TINand you think you might have
their NPI, and then you gosearch that file and what you
come up with is nothing.
And so it's really important tobe able to holistically look at
all of the rates under all ofthe TINs and NPIs for a specific
system to be able to pull underthat, especially with mergers,
(31:37):
acquisitions going on.
You can't just pull on a name.
You have to be able to identifythe specific TIN and NPI by
which you then do the pull Whichpresents another data complexity
and challenge that we kind ofhaven't covered.
Again, across multiple,literally thousands of files.
(31:58):
So now you're searching forhundreds of NPIs across
thousands of files, which again,not very human friendly.
Yeah.
And to that effect, that's notjust for hospital systems.
That's also for largerpractices, MSOs, IPAs.
You need to be able toholistically pull their
(32:18):
information.
The hospital system was just asmall example of that.
SPEAKER_03 (32:24):
So I would like to just circle back for a minute on
the fact that the patient thatis looking, shopping for
healthcare services and lookingat this data on the website, say
of their plan, there's no app,by the way, that was deemed to
be too burdensome at this time.
So they go to, an individualgoes to the plan website and
(32:47):
what they're going to get, acouple limitations on that data,
they're going to get anestimate.
And again, the exact executiveorder is looking to change that
and possibly include actualpricing information, not
estimates, but it'll be veryinteresting because the plans
don't likely have enoughinformation to commit to what
(33:08):
the price is in advance.
They'll get the code.
You have to put in the CPT code.
You have to get that from yourprovider and put that in the
insurance plan's website.
But coverage is a verycomplicated concept.
And so whether they would committhat they would pay that price
depends in part on whether theyview it as a covered service or
(33:31):
not.
And that might include, forexample, a medical necessity
review of whether the service isrequired.
So I'm not exactly sure what theactual prices mentioned in the
executive order will look like,but it'll be interesting to
follow.
And then one last point on thepatient data.
Remember, there's no qualitydata.
This is all cost information.
(33:53):
And so you're going to have togo to other places for that
quality data.
Perhaps CMS website has someinformation on quality for
hospitals, at least.
And so that's a piece of the theshopping experience, right?
Is you wanna pick a qualityprovider.
So this is all about cost.
So we really are at thebeginning stages, but in the
(34:14):
shopping experience, justunderstand.
And the last thing, actually,one other thing I thought of
was, if you're interested ingoing out of network, the data
is limited in that sense.
You'll get the allowed amountthat the plan is willing to pay,
which is not what you will bebilled by the provider.
So if you're going out innetwork, there's a high chance
(34:36):
that that allowed amount won'tcover the provider's full billed
amount.
And so that difference would bebalanced billed to you.
So you would have to go back tothe provider and get that data
from that provider.
So you as the patient have to doa lot of work pulling together
the provider and the plan, theproviders and the plans don't
have to work together to get youthis data.
(34:59):
So it's, it's, It's complicated.
I'll end on that note.
Do you guys have any otherspecific uses or limitations of
the data that you wanted toaddress that we didn't hit on?
No, I
SPEAKER_02 (35:16):
think that what your observation, your observations,
Jackie, are very on point, youknow, and really, you know,
rather than view it as sort of athis is just gonna be more
confusing or create moreconfusion.
I think looking at this as thefirst step and it's a small step
(35:41):
in the right direction that willeventually work together with
the other forces.
So a lot of times we have atendency to focus on one area,
The Affordable Care Act was amassive law and it has lots of
(36:05):
moving pieces.
There have been other componentsand other laws that have passed
things like MACRA with theQuality Payments Program, the
21st Century Cures Act, andthose types of laws that have
brought more clarity to wherethe transparency and coverage
rules need to go and thehospital transparency rules need
(36:28):
to go.
And so just keeping in mind thatit took us probably half a
century to get to the pointwhere we said, oh boy, We need
this clarified, and it's notgoing to get unwound with one
set of rules.
And again, transparency alsomeans something a little bit
(36:51):
different to each of thestakeholders in this whole
paradigm.
what transparency means to anindividual patient is something
very different than whattransparency means to a health
plan, to an insurer, to aprovider, and within the
(37:12):
provider organizations, there'sa lot of variation between
medical practice groups andhospital groups and health
centers and all those types ofthings.
So just keeping in mind thatthis is the first step,
giving...
We should give it a chance.
We shouldn't get too frustratedby it.
(37:33):
And enforcement isn'tnecessarily a bad thing, but we
have to remember that it costs alot to enforce.
And so it's really looking atthe ways that everyone can
benefit from the right pathforward here.
Well said.
SPEAKER_01 (37:53):
Yeah, absolutely.
Just to add a little bit more tothat, I think you're right.
This is just the first ofhopefully many steps towards
increasing price transparency.
And again, the large payers byand far are fairly compliant, at
least posting some reallycritical pricing information.
And again, our clients have usedthis information for contract
negotiations extraordinarilysuccessfully.
(38:16):
And while there's so muchcomplexity to it, it's really
good.
But then there's other...
non-compliance issues as youdelve deeper and deeper into it.
And, you know, some rates arenot published, some procedures
are not published.
So, you know, if you're lookingfor a very specific thing, it
might not be in there, or aspecific group might not be in
(38:37):
there.
So like an omission of a largehospital system that you know
exists.
And, you know, if you compare,interestingly, the hospital file
and the health plan file, whatdo you come up with there?
Sometimes some pricingvariation.
Sometimes you see that thehospital posted that information
while the health plan didn't.
(38:58):
So that's of interest.
But again, as we go further andfurther, hopefully there's more
compliance, more enforcement.
But by and large, thisinformation is extremely helpful
and it's a great first step, asKaren said.
So I absolutely echo and agreewith that.
SPEAKER_03 (39:16):
Lots
SPEAKER_01 (39:16):
to come.
SPEAKER_02 (39:17):
Yeah.
Well, it was great talking toboth of you today about this.
SPEAKER_01 (39:22):
Same.
Yeah, this
SPEAKER_00 (39:24):
is fun.
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For more information about AHLAand the educational resources
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And stay updated on breakinghealthcare industry news from
(39:45):
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