Delighted in revealing data wonders with powerful computers. Ordinary consumers, not so much.
That’s about three weeks of response to a data dump of massive proportions. Health insurers are posting their negotiated rates for almost every type of medical service across all providers.
But so much data is flowing in from insurers—thousands of huge digital files from a single insurer are not uncommon—that it can still take weeks for data companies to put it into usable forms for its intended targets: employers, researchers and even patients.
“The information is there; It’s just not accessible to people,” said Sabrina Corlett, a researcher at Georgetown University’s Center on Health Insurance Reforms.
Insurers are complying with federal rules aimed at price transparency that took effect July 1, he and others said. Realistically, though, consumers may have to wait until private firms synthesize the data — or until additional federal requirements begin to kick in next year aimed at making it easier for consumers to use price information to shop for prescribed medical care.
So why post the price? The theory is that disclosing this range of prices, which can vary widely for the same care, will help moderate future costs through competition or better price negotiations, though neither is a guarantee.
Hospitals came under a similar directive last year, stemming from the Affordable Care Act, to post what they agree to accept from insurers — and the amount they charge for cash-paying patients. Yet many have dragged their feet, saying the rule is costly and time-consuming. Their trade association, the American Hospital Association, sued unsuccessfully to stop it. Many hospitals never complied and federal government enforcement proved lax.
Although government regulators have sent more than 350 warning letters to hospitals and increased potential civil penalties from $300 to $5,500 a day, only two hospitals have been fined so far.
The requirements for insurers are broader than those facing hospitals, although they do not include cash value. This includes negotiated rates offered not only to hospitals, but to surgery centers, imaging services, laboratories, and even doctors. Also includes amounts billed and paid for “out-of-network” care.
Penalties for not posting can be higher than those faced by hospitals — up to $100 per day of violation, per affected enrollee, which adds up quickly for medium- or large-sized insurers or self-insured employers.
“We’re seeing higher compliance rates because of higher penalties,” said Jeff Leibach, partner at consulting firm Guidehouse.
Data is posted on public websites, but it can be difficult to access – mainly because of the size, but also because each insurer approaches it differently. Some, like Cigna, require visitors to cut and paste a very long URL into a browser to reach the price file’s table of contents. Others, including UnitedHealthcare, have created websites that directly list the table of contents.
Still, even the tables of contents are huge. UnitedHealthcare’s webpage warns that the page may take “up to 5 minutes” to load When it does, there are more than 45,000 entries, listed by plan or employer name for each year and job-based policies.
For consumers, accessing any single plan will be a challenge. At this point, it’s also difficult for employers, who want to use the data to determine how well their insurers negotiate compared to others.
Employers “really need someone to download and import the data,” which is in a format that can be read by computers but is not easily searchable, said Randa Deaton, vice president of buyer engagement at Purchaser Business Group on Health, which represents large employers.
After an initial blip, he saw a drastic change in costs.
“In one plan, I see negotiated rates ranging from $10,000 to $1 million for the same service,” Dayton said.
But the bigger picture won’t be clear until more data becomes clear: “The question is what story will this data tell us?” she said. “I don’t think I have an answer yet.”
Congress and administration policymakers hoped that insurer data would be overwhelming and that private firms and researchers would step in to produce deeper analysis and data.
One of those companies is Turquoise Health, which was “ecstatic about the amount of data,” said Markus Dorstel, vice president of operations.
The company, one of a number aiming to commercialize the data, downloaded more than 700,000 unique files, or nearly half a petabyte, by mid-July. For context, 1 petabyte is equivalent to 500 billion pages worth of typed text. It expects, Dorstel added, total downloads to end up in the 1- to 3-petabyte range.
Feroza will soon share the organized data with its paying customers — and will offer it free to general consumers shortly after on its website, which already lists available hospital prices.
What is possible now?
Let’s say patients know they need a certain test or procedure. Can they look online at the insurer’s data postings to choose a treatment site that will be the most cost-effective, which can be helpful for those who haven’t yet met their annual deductible and are on the hook for some or all of the costs?
“Maybe a person with a laptop could look at one of the files for a plan,” Dorstel said, but it would be difficult for consumers to compare insurers — even across all plans offered by a single insurer.
Consider, for example, what it takes to try to find a negotiated price for a particular type of brain scan, an MRI, from a particular insurer.
First hurdle: locating the right file. Google “clarity of coverage” or “machine-readable file” may pop up with an insurer’s name and results. Self-insured employers are also supposed to post the data.
Next step: Find the right plan, often from a table of contents that can contain thousands of names because insurance companies offer many types of coverage products or many employers have clients that must be listed.
Next is downloading and deciphering the jumble of codes to identify one that describes a particular service. It helps to have the service code, something a patient doesn’t know.
Starting January 1, another rule comes into effect that may provide some relief to consumers.
It involves apps and other tools that some insurers already provide for policyholders to estimate costs while preparing for a visit, test or procedure.
The new rule tightens what information is available and does not offer insurers to prepare such tools by January 1. Insurers must make available online or on paper, if requested, 500 government-listed patient costs. Selected, common “shoppable services,” including knee replacements, mammograms, various types of X-rays, and, yes, MRIs.
Next year — 2024 — insurers must pay consumers cost-sharing amounts for all services, not just the initial 500.
Another regulatory layer stems from the No Surprises Act, which went into effect this year. Its overarching goal is to reduce the number of insured patients who receive higher-than-expected bills for care from out-of-network providers. Part of the law requires providers, including hospitals, to provide an upfront “good faith estimate” for non-emergency care when asked. Right now, that part of the law only applies to patients who are uninsured or use cash to pay for their care, and it’s unclear when it will begin to apply to insured patients using their coverage benefits.
When this happens, insurers require policyholders to provide cost information before they receive care in a format known as an advance explanation of benefits — or EOB. It includes how much the provider will charge, how much the insurer will pay — and how much the patient will owe, including any outstanding deductibles.
In theory, this means there could be both an upfront EOB and a price comparison tool, which a consumer could use before deciding where or from whom to get services, said Corlett at Georgetown.
Still, Corlett says, given all the complexity, he remains skeptical that “these tools will be available in a usable format in real life, for real people, anywhere near the timeline they were designed for.”
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