'Our job is much bigger than just publishing rates': The steps ahead for payers' pricing data

It's now been over six months since consumers gained access to healthcare pricing information through their health plans — but some experts say the published data is largely unusable or doesn't steer patients in the right direction for care.

Since July 1, payers have been required by CMS to disclose in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for all covered items and services.

But the useability of the published pricing data is being hindered because it's hard to find, difficult to understand, and the sheer size of it all is massive. It would take 76,104 decades to count up all the data available in machine-readable files, according to San Diego-based transparency data startup Turquoise Health.

"There's a lot of data out there, especially from the payer side and the hospital side," Marcus Dorstel, vice president of operations at Turquoise, said. "What we're seeing is companies are still building out the tools that consumers will use to really make it useful to allow customers to shop around for services." 

Amino Health is a San Francisco-based company that's been looking through the pricing data that was available prior to the transparency rules from both payers and hospitals. According to co-founder and CEO David Vivero, the data can provide a "notion of price," but prices alone don't provide patients with the choices they need to find the highest-value care for them.

"A lot of what we try to bring to this experience is a really trusted third party that helps bring a lot of that integration," he said. "The only reason this regulation exists is not to publish the rates, but to get people to act on that information to choose providers that are less expensive. Our job is much bigger than just publishing rates."

Since the start of this year, payers themselves have been required to provide an internet-based price comparison tool that allows members to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider for 500 items and services. Price comparison tools must include all services, including prescription drugs, by 2024. 

According to AHIP, nearly 94 percent of commercial insurers were already providing their members with online care cost estimator tools as of July.

Another challenge according to Mr. Vivero is that the data from payers is incomplete, though that's not necessarily out of bad faith or a lack of effort on the part of insurers.

"What we're hearing about from a lot of payers is that they're going forward with partial implementations or just trying to get portions of the business online because it's just so hard," he said.

In a new report from Georgetown University, the authors say the published data is largely unusable for researchers because of its size and complexity. They described much of the payer pricing data as being "of questionable quality" and "too large to access without a supercomputer."

"Trying to locate a single provider in the [transparency in coverage] files is akin to trying to find a single word in a very large dictionary that isn’t in alphabetical order," the report said.

The researchers proposed potential solutions to CMS for improving the usability of pricing data for both researchers and policymakers, including reducing redundancy through new file structures, improving accessibility through a standardized labeling system, and expanding oversight of data quality.

"I love what the regulations are doing because they're really raising the floor and very meaningfully," Mr. Vivero said. "But above and beyond that, we need to invest in things that not only add new dimensions to this, but also recognize that there are certain emotional and other needs that people have when making these choices."

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