Our organization has been in the business of delivering price transparency to medical consumers for six years. Our website allows users to shop for more than ten thousand medical tests and procedures, review the alternatives across more than one hundred thousand medical providers, and choose the care that best meets their needs based on the merits of cost, quality, and convenience. We have existing relationships with hundreds third-party administrators, medical benefits brokers, industry clearinghouses, and other advisors. Among our many sources of post-adjudicated claims data are several state all-payer claims databases (APCDs), private payers, and our users. We believe that we have the largest database of post-adjudicated medical claims used for this purpose in the country.
On page 34, the Departments state that the negotiated rate must be provided “…to the extent necessary to determine the participant’s, beneficiary’s, or enrollee’s cost-sharing liability.” Disclosure of these amounts, notwithstanding their applicability to determining the individual’s cost-sharing amount, should be required in all cases.
Nearly half of the national spend on healthcare is incurred by the most expensive 5% of patients. Regardless of health plan design, the most expensive of these patients will satisfy all deductible and out-of-pocket amounts required under their plan and incur no personal incremental cost for additional medical care. Without the requirement to display negotiated rates in all cases, these individuals will have no insight into the true cost of care, which is a disservice to themselves, their employer, and others whose premiums are based on the same risk pool.
The impacts of the exceptionally high cost of healthcare in this country go far beyond out-of-pocket liability. In the case of employer-sponsored plans where employers fund a portion of ever-rising premiums, it means less cash compensation for employees and decreased capacity for investment in the business. In the case of individual marketplace plans, it means exorbitant year-over-year increases in premiums borne in some cases by taxpayers when premium subsidies are offered.
If we have truly done away with the fiction that network-negotiated rates for care are confidential and proprietary, and this information is being made available in machine- readable format for public use, then this information must be shown on all requests for price made by consumers. Without it, even the most motivated consumer cannot exercise full control over their purchasing power.
On page 46, the Departments solicit comment regarding other refining and reordering functionality that should be required of the internet-based self-service tools. Other valuable refining and reordering features should include an ability to display only in- network providers and an ability to filter or sort by provider quality if a quality metric is made available.
On Page 48, the Departments seek comment regarding the value or necessity of mobile applications in delivering an internet-based self-service tool and the relative resource requirements for developing such and application. Mobile applications, and at minimum, a web platform with fully responsive web design (RWD), from which users can access negotiated rate and cost-sharing liability amounts are imperative to the goals of this administrative rule.
Consider, for example, the case where a patient has scheduled a visit with their primary care physician (PCP) to discuss an issue which will require a specialist referral and further diagnosis and treatment procedures. In this fleeting moment when patients are in the presence of their PCP, they are best able to make informed decisions for their continuing healthcare needs based on the merits of cost, quality, and convenience. Requiring mobile applications, integrated with the particularities of their health plan, would mean that network and personalized cost information are at the patient’s fingertips and can be used to weigh their options and select a provider for follow-on care that meets their specific needs.
Furthermore, it is essential to provide access to this critical information to the patients while they are with their doctors in order to preserve the integrity of the patient-doctor relationship. Decisions about care should not be pushed onto patients alone. Mobile access to the application ensures that patients can make decisions based on cost, quality, and convenience with the input and consideration of their trusted doctors.
Using the proper architecture for a browser-based website, namely a responsive web design (RWD), would ensure that the additional resources necessary to create a mobile application would be negligible. The additional efficiencies created for patients and providers far outweigh the additional development and maintenance costs of a mobile application.
On page 50, the Departments seek comment regarding whether additional methods of providing information, besides the internet-based self-service tool and requests by mail, should be required. Given the volume of information that a given request could produce and the potential complexity of the information, which may include several line items for bundled services, each with their respective negotiated rate, estimated member responsibility, pre-requisites to care, and disclaimers, responses should be in written form. This would preclude providing information over-the-phone or in-person. Other media in which responses should be required to be distributed, if desired by the consumer, include email and facsimile.
On page 66 the Departments requested comment on the potential benefits of requiring the charged amount to be a required field of the Allowed Amount File. Consumers would benefit from this data field being included in the Allowed Amount File. Hospitals and other providers often express their cash-pay rates as a percentage discount from the chargemaster rate. Third-party companies could use this information, compiled from the machine-readable Allowed Amount Files contemplated in this rule from one or more entities, to develop an application to display cash-pay rates to consumers. Consumers could use this information if they were uninsured, or if they wanted to seek care outside of their network based on the services available from, or quality of, a certain out-of-network provider. In this way, consumers could perform a meaningful cost-benefit analysis including desirable options which would have otherwise been unknowable.
Consider, for example, a patient from New Hampshire, who purchased insurance with a network composed almost entirely of NH-based providers. There are only 31 hospitals in the state, none of which would be considered world-class facilities. Nationally, there are dozens of world-class facilities, performing cutting-edge medical research in every specialty. This patient from NH could use a tool like the one proposed above to see cash pay rates from providers like the Mayo Clinic, which publicly advertises the availability of discounted cash pay rates which are available for uninsured or underinsured patients who require care based on medical necessity.
On pages 67 and 68, the Departments seek comment on the proposed 90-day reporting period for plan allowed amounts for out-of-network care. Given that this allowed amount will have much more to do with the plan design than the charged amount, since there are no negotiated rates for out-of-network care, this reporting period should be stretched beyond 90 days to at least 180 days. The longer the period, the more likely there will be 10 or more observations of a given combination of out-of-network provider and service, which the Departments have determined is sufficient to protect patients from reidentification.
On pages 68 and 69, the Departments request comment regarding potentially setting the minimum claims threshold higher than 10, perhaps to 20. The CMS Cell Size Suppression Policy, which dictates in part the standards that must be met by CMS data users to mitigate the risk of individual reidentification, require reporting to be suppressed on any value that was aggregated from fewer than 11 records. This standard has been in place in relation to the use of CMS data for at least 10 years and hasn’t required revision in that period. A higher minimum claims threshold is not necessary to prevent reidentification. Additionally, raising this threshold will not substantially change the complexity in complying with this rule. If the underlying source information has been organized in a way that enables querying for cells with 20 or more records, it can be queried for cells with 10 or more records.
On page 71, the Departments request comments regarding whether the machine- readable files should be combined into a single file to ease maintenance requirements for plans and issuers. Given that the field definitions in each file as they are proposed are dissimilar and these files would likely be generated from different sources, these files should remain separate. The additional burden of generating or ingesting a single file with dissimilar data but standard definitions for each field is not substantially different from generating or ingesting two files with homogeneous data and standard definitions.
On page 72, the Departments request comment regarding the internet location of the machine-readable publicly available Negotiated Rate and Allowed Amount Files. Plans and issuers should be required to notify CMS of the web address(es) at which these files can be found, which CMS in turn will publicize. Allowing plans and issuers to select their own location for these files, when there is no requirement to publicize that location, creates a very substantial burden on innovators and other potential users. This location could presumably change each month. Furthermore, innovators wouldn’t necessarily know who was in compliance and was hosting a file or when they had collected files from all issuers and payers in compliance. In contrast to the other requirements of the rule, the additional burden of notifying CMS of the location of their file is insignificant, especially if the location does not change from monthly update to monthly update.
On page 73, the Departments request comments regarding the frequency of updates that should be required for the Negotiated Rate File. The proposed 10-day period in which plans and issuers must update negotiated rate information seems reasonable. Allowing plans and issuers more time to update this information would result in the information becoming stale and difficult for patients to rely on when making decisions about their care. A requirement to update Negotiated Rate Files more frequently than 10 calendar days would be more useful for patients, but we recognize that it could create undue burden on plans and issuers to comply. As such, we believe the proposed rule of 10 calendar days seems reasonable.
On page 77, the Departments solicit comment on the merits of a publicly accessible API to access negotiated rates and out-of-network allowed amounts in place of the machine-readable files. The additional certification and interoperability burdens of APIs are not offset by their proposed benefits. Even with strictly defined standards, most entities would struggle to implement and support the APIs as proposed, mitigating the benefits of APIs to innovators and other developers. Furthermore, the difference between having completely up-to-date pricing information as compared to pricing information which is at the most 30 days old is marginal. The Departments should certainly refrain from requiring such APIs. While some entities may decide to create APIs to transmit this information, the format of the machine readable files contemplated in this NPRM should be required as proposed.
On pages 97 and 98, the Departments pose several questions regarding the complementary nature of quality metrics to the goal of increasing price transparency. Displaying quality metrics alongside pricing information on the internet-based self- service tools is critically important. The price and quality of care are totally unrelated. Naïve users may infer that low-cost facilities who offer the care they need are of poor quality, while expensive alternatives are of comparatively higher quality, which would have the unintended and damaging effect of increasing the amount spent on care. This is a mindset that comes naturally to consumers today given that higher prices in nearly every other category of goods—for example, cars, snow shovels, or televisions—imply a correspondingly higher value. However, the market for healthcare is not currently transparent, consumers have not been able to effectively navigate and shop the healthcare marketplace, and prices do not conform to expectations of markets for other goods. Furthermore, users should be empowered to avoid low-quality facilities, no matter their cost, as the market evolves to serve a discerning, price-conscious consumer.
Selecting and/or designing an appropriate metric to gauge provider quality presents several challenges. Outcomes-based metrics tend to penalize providers who treat the most complex cases. Continued focus on risk-adjustment measures is likely to make this category of quality metrics the most useful. Process measures can be too rigid in defining the appropriate course of care which may not be appropriate to treat certain individuals. Structural measures only attempt to measure the right conditions in which quality care is likely to be delivered rather than measuring the care at all. Plans and issuers should have the freedom to select a quality metric that they believe best serves their population. All of the organization and government generated quality measures mentioned in the text should be options for reporting quality, as should measures that attempt to develop composite scores, or measures that are proprietary in nature.
On page 113, the Departments write “Transfers from providers to consumers and issuers of approximately $128 million per year as a result of lower medical costs for issuers and consumers by allowing issuers to share with consumers the savings that result from consumers shopping for care from lower-cost providers.” In comparison to the costs to develop and implement these transparency systems, this number is unimpressive. The true potential for such a comprehensive set of tools if consumers actually engage with them is in fact much higher. Out-of-pocket expenditures plus private health insurance expenditures in 2018 totals $1.6 trillion. If 5% of consumers engage with these tools and are able to reduce the cost of their care by 5%, there would be $4 billion in savings created. If 25% of consumers engage with these tools and are able to reduce the cost of their care by 10%, there would be $40 billion in savings created. If 100% of consumers engage with these tools and are able to reduce the cost of their care by 20%, there would be $320 billion in savings created. None of these figures consider changes to the competitive landscape in the healthcare market, which will see providers competing for volume in a market with transparent prices. Plans and issuers that are truly incented to negotiate the lowest prices possible with providers could result in a market that behaves much more efficiently overall, driving additional savings that are entirely separate from the savings driven from actual shopping activity by healthcare consumers.