Databases with powerful computers are very happy. Casual consumers, not so much.
That’s what happens in two weeks and I lose a lot. Health insurers post their negotiated rates for each type of health care they provide to all providers.
But so much is flowing from insurers – tens of thousands of digital files from one insurer is not uncommon – that it will take weeks for information companies to put it into usable form for what they want: employers, researchers and patients. .
“There’s a lot out there; it’s not available to the general public,” he said Sabrina Corletteresearcher at Georgetown University’s Center on Health Insurance Reforms.
Insurers are complying with federal rules targeting price transparency that began July 1, he and others said. In reality, however, consumer use will have to wait until companies develop it — or other government requirements begin next year to make it possible for consumers to use price information to purchase prescribed health care.
So why the prices? The idea is that making these prices public, which can be very different from the same care, will help reduce future costs through competition or price negotiations, although nothing is guaranteed.
Hospitals last year had similar guidelines, which stem from the Affordable Care Act, to submit what they’ve agreed to accept from insurers — and the amount they’re billed to co-pay patients. However many they dragged their feet, saying the law is expensive and time-consuming. Their trade association, the American Hospital Association, He was sued but unsuccessful to stop it. Many hospitals have not taken action and the federal government has determined that they are not doing well.
When the government authorities send more than 350 warning letters to hospitals, and increased the potential fine from $300 a day to $5,500, only two hospitals have been paid so far.
Insurance requirements are much greater than what hospitals face, even if they don’t include premiums. It includes negotiated fees paid not only to hospitals, but also to operating rooms, imaging services, laboratories, and even doctors. Out-of-network care costs are also included.
The penalty for not sending can be higher than what the hospitals face – $ 100 per day for the violation, for the subscribers involved, which only increases quickly for medium or large insurers or employers who are insured.
“We see people obeying the law because of the many penalties,” he said Jeff Leibacha partner in the consulting firm Guidehouse.
Hard to find information
The data is posted on public websites, but it can be difficult to find it – mainly because of its size, and because each insurance company approaches it differently. Others, like Cigna, requires viewers to cut and paste a very long link into the browser to get to the list of content in the tree files. Others, including UnitedHealthcarecreated websites that list content.
However, even the internal documents are large. UnitedHealthcare’s website warns that it may take “up to 5 minutes” for the website to load. In that case, there are more than 45,000 entries, which are listed by year and name of the organization or employer.
For consumers, finding every plan together can be difficult. Currently, it is difficult for employers, who want to use the information to know how well their insurance companies negotiate compared to others.
Employers “really need someone to download and import the data,” which is in a computer-readable but not easily searchable format, he said. Randa Deatonvice president of consumer affairs at the Purchaser Business Group on Health, which represents major employers.
After the first look, he noticed a big difference in prices.
“In one plan, I can see negotiated prices ranging from $10,000 to $1 million for the same job,” Deaton said.
But the bigger picture won’t be clear until the data is cleaned up: “The question is what story will the data tell us.” he said. “I don’t think we have an answer.”
Congressional policymakers and regulators expect that insurance data will become larger and that private companies and researchers will step in to analyze and generate data.
One of those companies is Turquoise healthwho was “very excited about the amount of data,” said Marcus Dorstel, vice president of operations.
The company, which is one of the people who want to sell the product, had lowered it more than in July 700,000 unique files or about half a petabyte. In context, 1 petabyte is similar 500 billion pages of standard text. The hope, Dorstel added, is that full downloads will end up in the 1- to 3-petabyte range.
Turquoise hopes to share the plan with paying customers soon — and offer it free to regular consumers at a later date on its website, which already lists current hospital prices.
What you can do now
What is possible right now?
Let’s say patients know they need a particular test or procedure. Can they look online for insurance quotes to choose the least expensive treatment center, which would be helpful for those who have not met their annual deductible and are at risk of some or all of the costs?
“Maybe someone with a laptop can look at one file for one plan,” Dorstel said, but consumers may struggle to compare between insurers — or even across all plans offered by one insurer.
For example, consider what it takes to try to get a negotiated price for a certain type of brain scan, MRI, from a real insurance company.
The first hurdle: finding the right file. Google “transparency in coverage” or “machine readable files” with the name of the insurer and the results will appear. Self-insured employers must also submit data.
Next: Get a real plan, often from content that can include thousands of names because insurance companies offer many types of services or have many customers that need to be rewritten.
Downloading and identifying combinations of codes to identify one that describes a specific function is next. It helps to have a service number, which the patient may not know.
Starting from Jan. 1, another law applies which can provide relief to consumers.
It also includes software and other tools that some insurers already provide to policyholders to estimate costs when planning a trip, test or procedure.
The new law reinforces existing provisions and requires insurers that do not offer such tools to be ready by that date. Insurers must be available online, or on paper, if requested, the patient’s price for a list of 500 selected by the government“consumer services” are commonly available, including knee replacements, mammograms, multiple types of X-rays, and, yes, MRIs.
The following year – 2024 – insurers must offer consumers a cost-sharing plan for all services, not just the first 500.
Explaining benefits and comparing costs
Another piece of regulation comes from the No Surprises Act, which came into effect this year. Its main goal is to reduce the number of insured patients who receive more than they expect to receive care from out-of-network providers. Another section of the law requires providers, including hospitals, to provide a “reasonable expectation” of emergency care upon request. Right now, part of the law only applies to patients who don’t have insurance or who are paying for their care, and it’s not clear when. it will kick for insured patients who use their benefits.
In such cases, insurers will be required to provide cost information to policyholders prior to receiving care described as an advance explanation of benefits – or EOB. It may include the amount the provider will pay, how much the insurance will pay – and how much the patient owes, including the amount owed.
In theory, that means there could be an EOB up front and a price comparison tool, which a consumer can use before deciding where to get it or from whom, Georgetown’s Corlette said.
However, Corlette said, he remains skeptical, given all the challenges, that “these tools will be available in a way that can be used, in real life, for real people anywhere near the expected time.”