It’s out there, but it’s not for the faint of heart.

insurance costs

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

That’s the reaction some three weeks after a daunting data dump. Health insurers publish their negotiated rates for almost all types of medical services they cover from all providers.

But so much data is pouring 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 their intended targets: employers, researchers, and even patients

“There’s data out there, it’s just not accessible to mere mortals,” said Sabrina Corlette, a researcher at Georgetown University’s Center for Health Insurance Reform.

Insurers are complying with federal rules intended to price transparency that went into effect July 1, she and others said. Realistically, however, consumer use of the data may have to wait until private companies synthesize it, or additional federal requirements begin rolling out next year aimed at making it easier for consumers to use data. pricing information to purchase scheduled products. medical care.

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

Last year, hospitals submitted to a similar directive, stemming from the Affordable Care Act, to publish what they agreed to accept from insurers and the amounts they charge patients who pay cash. However, many held back, saying the rule is expensive and time-consuming. His trade association, the American Hospital Association, unsuccessfully sued to stop him. Many hospitals simply never complied, and federal government enforcement has been lax.

While government regulators have sent more than 350 warning letters to hospitals and increased potential civil penalties from $300 a day to as much as $5,500, only two hospitals have been fined so far.

The requirement for insurers is broader than the one faced by hospitals, although it does not include cash prices. It includes negotiated rates paid not only to hospitals, but also to surgical centers, imaging services, laboratories, and even physicians. Amounts billed and paid for “out-of-network” care are also included.

The fines for not posting can be higher than those faced by hospitals: $100 per day per violation, per affected member, which quickly adds up for mid-sized or large insurers or self-insured employers.

“We’re seeing high compliance rates because of the high penalties,” said Jeff Leibach, a partner at consulting firm Guidehouse.

The data is published on public websites, but it can be difficult to access, mainly due to 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 the pricing file’s table of contents. Others, including UnitedHealthcare, have created websites that directly list a table of contents.

Still, even the tables of contents are huge. UnitedHealthcare’s website warns that the page could take “up to 5 minutes” to load. When you do, there are more than 45,000 entries, each listed by year and plan or employer name for work-based policies.

For consumers, accessing any individual plan would be a challenge. At the moment, 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 computers can read but isn’t easily searchable, said Randa Deaton, vice president of buyer engagement at the Health Buyers Trade Group. , which represents large employers.

After an initial look, you’ve seen 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: “The question is what story will this data tell us?” she said. “I don’t think we have the answer yet.”

Legislators in Congress and the administration expected the insurer data to be overwhelming and private businesses and researchers would step in to do the deep analysis and data production.

One such company is Turquoise Health, which was “delighted with the amount of data,” said Marcus Dorstel, vice president of operations.

The company, one of those seeking to commercialize the data, had downloaded more than 700,000 unique files, or about half a petabyte, by mid-July. For context, 1 petabyte is the equivalent of 500 billion pages of standard written text. Their expectation, Dorstel added, is that the total download will end up in the range of 1 to 3 petabytes.

Turquoise hopes to share organized data with its paying customers soon, and offer it for free to ordinary consumers at some later point on its website, which already lists available hospital prices.

What is possible right now?

Let’s say patients know they need a specific test or procedure. Can they search online for insurer data releases to choose a more cost-effective treatment site, which could be helpful for those who haven’t yet met their annual deductible and are forced to pay some or all of the cost?

“Maybe a person with a laptop could see one of the plan files,” Dorstel said, but consumers would find it hard to compare across insurers, or even across all plans offered by a single 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.

The first hurdle: locating the right file. Google “transparency in coverage” or “machine readable files” with an insurer’s name and the results might come up. Self-insured employers must also 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 so many types of coverage products or have so many employer clients that they also need to be listed.

The next thing is to download and decipher the tangle of codes to identify one that describes a specific service. It is helpful to have the service code, something a patient may not know.

Starting January 1, another rule will go into effect that could provide some relief to consumers.

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

The new rule tightens what information is available and requires insurers that don’t offer such tools to have them ready by January 1. Insurers must make available online, or on paper, if requested, the patient cost for a list of 500 government documents. Common and select “commercial 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-sharing amount for all services, not just the initial $500.

Another regulatory layer stems from the No Surprises Law, which came into effect this year. Its overall goal is to reduce the number of insured patients who receive higher-than-anticipated bills for care from out-of-network providers. Part of the law requires providers, including hospitals, to give a “good faith estimate” in advance for non-emergency care when requested. Right now, that part of the law applies only to patients who are uninsured or use cash to pay for their care, and it’s unclear when it will apply to insured patients using the benefits of their coverage.

When it does, insurers must provide members with cost information before they receive care in a format described as an advance explanation of benefits, or EOB. It would include 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, that means there could be an initial EOB and price comparison tool a consumer could use before deciding where or from whom to get service, Corlette said in Georgetown.

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


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2022 Kaiser Health News.
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Citation: Health Insurance Price Data: It’s Available, But It’s Not for the Faint of Heart (2022, Aug 1) Retrieved Aug 2, 2022 from https://medicalxpress.com/news/2022-08-health -price-faint-heart .html

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