“How do you make a spreadsheet or database of 50,000 lines of high-tech clinical billing information for consumer convenience?”
That’s the question Neil Brennan asked in a recent interview after the Centers for Medicare and Medicaid Services imposed the first fine on the Atlanta health system. After serving as CMS’ chief data officer and senior analyst on the Medicare Payments Advisory Committee, he has been closely monitoring the implementation of price transparency legislation over the past year and a half. He and other price transparency experts argue that CMS’ rules are fundamentally flawed by design and impose extremely demanding requirements on hospitals, but medical technology companies may be able to help.in view of Compliance rate keep it low CMS began issuing larger fines, and the hospital’s efforts to find answers to his questions became more urgent.
CMS starts its execution Price Transparency Rules The first day of 2021. The law requires hospitals to publish their total fee, payer-specific negotiated fee, de-identified minimum negotiated fee, de-identified maximum negotiated fee, and cash price on their website in machine-readable documents. It also requires hospitals to publish pricing for the 300 most commonly used services on their websites in a consumer-friendly manner.
recent study published in JAMA Fewer than 6% of hospitals were found to be in full compliance with CMS’ price transparency rules. Compliance has been low since the law went into effect more than two years ago, but the agency’s proposed fines for violations were initially “so low that they had no impact on whether a hospital was compliant,” Brennan said.A bigger driver for hospital compliance, he argued, was whether they were “finished in the court of public opinion,” referring to media reports This puts hospitals at a disadvantage by not complying with regulations or by failing to publish information in an accessible way.
However, on June 7, things took a turn.That’s when CMS was hit North Atlanta Hospital fined $1 million became The country’s first health system to face the wrath of CMS for lack of compliance. Brennan said many other health care leaders were confused about the fines because CMS issued hundreds of warnings to hospitals months ago, but actually imposed fines on only one health care system.
The reason why Northside Hospital was fined but others were fined remains unknown, although many speculate that the health system’s leadership may have been particularly defiant in its communications with CMS. Penalties could inspire more compliance at hospitals, as a $1 million fine is an unexpected expense that is sure to put pressure on CFOs at nearly all hospitals.
Marcus Dorstel, VP of Operations, Price Transparency Software Startup Turquoise HealthAgreed that if CMS continues to issue tickets like Northside Hospital does, the hospital will have to take compliance more seriously.
“This could make it difficult for hospital leadership to justify to the board, shareholders or the community why they have millions of dollars on their books because they are not complying with federal law,” he said.
There are several reasons why hospitals are struggling to meet CMS requirements, said Dr. Nick Patel, chief digital officer at South Carolina-based Prisma Health. First, there are so many permutations of the actual cost of a procedure that it is nearly impossible to estimate exactly what a patient will ultimately pay. For example, the true cost of a gallbladder removal can be thousands of dollars higher than what a patient sees on a price estimator due to surgical adhesions, excessive bleeding, or other unforeseen complications that may arise during the procedure.
“It’s a best guess ‘maintenance estimate’ like what your mechanic or air conditioning company will give you,” Dr Patel said.
Another reason price transparency is tricky for hospitals is that patients are primarily concerned with their out-of-pocket costs, not “retail” or “unadjusted” costs.Since this varies based on the patient’s health plan and deductible, the technical improvement for the hospital to calculate an accurate estimate is more onerous.
Disparities in care in the healthcare industry also make it difficult for hospitals to provide effective price transparency tools. The documentation, coding and other ancillary costs involved in the medical billing process are complex, and surgeons may have different preferences for the amount of equipment they use in each case, Dr. Patel said. He said hospitals should continue their efforts to reduce disparities in care to better standardize costs.
All of these complexities in the medical billing process make it difficult for patients to understand the price transparency data they encounter. Brennan said he’s spoken to doctors who say they can’t understand the pricing information the hospitals release, so expecting consumers to digest the information CMS is asking hospitals to release is very optimistic.
Dorstel says his startup, along with other medical software companies, likes Healthcare Blue Book and cedar — Can play an important role in accelerating hospital compliance, as most hospitals do not have the technical knowledge and staff required to create tools that present comprehensive billing information in a consumer-friendly manner. Cedar CEO Florian Otto agreed, saying that most hospitals he spoke with about price transparency compliance told him they didn’t have any staff with experience with the digital tools needed to build CMS.
“While I think the intent of the regulations is very good, the enforcement is a bit unfair because you’re asking an entity to do something that doesn’t actually exist a product,” Otto said.
As health tech companies like his start producing software to help hospitals comply with CMS rules, Otto says they need to focus not just on software, but engagement as well. Most of the technology partners currently helping hospitals with compliance are enterprise software companies, which often struggle to create engaging tools because they build technology to meet the needs of organizations rather than individual users, he said.
In this sense, engagement means not only creating tools that consumers can easily interact with, but also having access to this pricing data. Six months after CMS began enforcing its rules, an investigation by the Kaiser Family Foundation established Only 9 percent of U.S. adults nationwide know that hospitals must disclose their pricing information online.
The fact that few Americans appear to use price-transparency data to buy health care shows that CMS’ rules have not come close to achieving their stated main goal: empowering patients more. Otto said minimal awareness and use of hospital pricing data may not be an issue for the time being, as hospitals issue tools that are too complex to help patients actually buy care.
“Hospitals aren’t following the rules because it’s very difficult to do something that really doesn’t confuse patients,” he said. “That’s what usually happens when you’re doing exactly what CMS says — it really confuses patients.”
Photo: Adventurer, Getty Images
