Phia GroupPhia Group Mediahttps://phiagroup.com/Media/PostsPrice Transparency: A Chief Concern at SIIA’s Recent Kanas City Forumhttps://phiagroup.com/Media/Posts/PostId/1230/price-transparency-a-chief-concern-at-siias-recent-kanas-city-forumBlog,Health Insurance,Healthcare Costs,Hospital BillsThu, 09 Mar 2023 20:23:30 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">KANSAS CITY, MISSOURI – In the opening presentation of the SIIA Price Transparency Forum held at the Kanas City Marriott Downtown last month, SIIA’s Senior Vice President of Government Relations, Ryan Work, made a bold prediction: if healthcare costs remain on this decades-long rising trajectory it could lead to the demise of employer-based healthcare as we know it.  </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Judging by the ensuing statistics presented, this was no hyperbole. Per the report delivered by Work and his co-presenter, Chris Condeluci, SIIA’s Washington Counsel, from 2016-2020, healthcare prices increased at double the rate of inflation—a trend that was only exacerbated by the COVID pandemic, as evidenced by the average premium for employer-provided family healthcare shooting up to $22,221 in 2021, which equates to one third of the current median American household income and represents a threefold increase from 2001. Indisputably, a primary culprit behind the exorbitant and, in many cases, wasteful healthcare spending is the opaque pricing practices employed by many providers—as well as the ambiguity and flaws inherent in the No Surprises Act (NSA) that was resultingly passed to safeguard patients from receiving surprise medical bills stemming from <span style="background:#fafafa"><span style="color:black">many emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.</span></span> </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">On some level, the NSA, which went into effect on January 1, 2022, <i>has</i> delivered intended results. Consider that in the act’s first nine months of existence, approximately nine million surprise bills were prevented. However, within this newly rolled-out surprise billing arbitration process, the sheer volume of disputes submitted has been downright overwhelming. As Work and Condeluci explained, going into 2022, it was originally estimated that there would be 17,000 out-of-network payment disputes submitted for the entire calendar year; however, between April 15 and September 30 of last year, that number would swell to 90,000, a disproportionate number of which (23,000) came from Texas and were often ruled ineligible for federal arbitration. Alas, the ineligibility issue did not just pertain to Texas: by Work and Condeluci’s estimation, there were 41,814 disputes challenged for eligibility from April-September 2022. During that six-month period, 23,107 disputes were closed, 15,895 (69%) of which were ultimately deemed ineligible. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Such statistical findings beg the question: why was there such an exorbitant number of claims ruled ineligible? For starters, many of these claims should have been subject to their respective states’ surprise billing laws—not the federal NSA. Secondly, there are some claims filed that are Medicare related. Additionally, and perhaps most significantly, there have been quite a few providers who are bypassing the initial processes in accordance with the NSA (i.e., the initial 30-business day payment process upon receipt of the claim, which precedes the open negotiation process, also spanning 30 business days) and going straight to the independent dispute resolution (IDR) process. Meanwhile, an ineligible claim can also result from the poor transmission of information into the portal, a dilemma that is only made worse by the absence of a provider’s contact information. (It’s also worth noting that literally 10 providers/provider vendors are filing 75 percent of arbitration claims, leaving those responsible to be inundated with an often unreasonable amount of administrative work.) In sum, if all parties are not following the guidelines of the NSA, there will be an untold number of claims found ineligible. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The other notable hindrance to consumers reaping the benefits of more transparent pricing is the unfortunate reality that many hospitals have simply flouted NSA regulations. At the SIIA Price Transparency Forum, it was noted that while partial hospital compliance increased considerably from 2021-2022, a whopping 85 percent of hospitals are still not complying with the federal requirements to publicly post prices for offered services. Perhaps even more disturbingly, as Condeluci and Work noted, HCA Healthcare, America’s largest for-profit hospital system, one that contains 188 hospitals, remains entirely noncompliant with the federal price transparency rules inherent in the NSA. Further, per Condeluci and Work’s report, of the 361 hospitals owned by HCA Healthcare and fellow industry titans, Ascension and CommonSpirit Health, merely two comply at this hour. Such utter disregard of a law brimming with far-reaching potential is surely a discouraging situation, but perhaps one that can be rectified going forward. </span></span></span></span></span></span></p> <p><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Clearly, there are quite a few roadblocks to there being comprehensive price transparency within the American healthcare system. And that’s without even getting into the often not-so-user-friendly data presented to healthcare consumers shopping around for procedures and services … certainly a topic for another day.</span></span></span></p> 1230Hospital Prices: Fully Transparent or Still Somewhat Opaque?https://phiagroup.com/Media/Posts/PostId/1227/hospital-prices-fully-transparent-or-still-somewhat-opaqueBlog,Cost Containment,Health Insurance,Healthcare Costs,Hospital BillsThu, 23 Feb 2023 17:59:27 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">January 1, 2021. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span new="" roman="" style="font-family:" times="">In the throes of the first pandemic winter, still months before coronavirus vaccines would roll out in earnest, the Hospital Price Transparency Rule went into effect. It was a promising development in the world of healthcare cost containment—hospitals were now obligated to provide a single, machine-readable digital file containing standard charges for all services and items provided by the facility. Said charges included <span style="background:white"><span style="color:#333333">gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges. In order to be fully compliant with the novel legislation, hospitals were also mandated to present a user-friendly list of at least 300 “shoppable” services, ones that patients could schedule in advance. But now, two years removed from the rule being introduced, it behooves medical practitioners, patients, and legislators alike to assess whether the Hospital Price Transparency Rule has accomplished its overarching goal of empowering healthcare consumers to reap the benefits of a competitive marketplace. </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""><span style="color:#333333">Evidently, there’s not one definitive answer. </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""><span style="color:#333333">Earlier this week, <i>U.S. News & World Report</i> shared some encouraging news by reporting that a majority of hospitals are<i> </i>in compliance with the 2021 federal price transparency rules. More specifically, the report cited Medicare Director Dr. Meena Seshamani’s calculation that after merely 27% of hospitals complied in 2021, 70% of medical institutions acted in accordance with federal regulations this past year. Put another way, in 2022, millions more Americans were able to sit in their living rooms or studies and download comprehensive but nevertheless relatable files that delineate the prices charged by various hospitals for their upcoming cataract surgeries or colonoscopies. Resultingly, the likelihood of depressingly high medical bills landing in their mail slots in the months ahead decreased significantly. </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""><span style="color:#333333">While the aforementioned trend surely represents heartening news, simple arithmetic dictates that 30% of hospitals are still <i>not </i>in compliance. Why, exactly, were so many not doing their due diligence in posting the consumer-friendly pricing displays and readable files, especially given the heightened financial penalties for not obliging? </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""><span style="color:#333333">It’s possible that for some behemoth healthcare institutions, a six-figure penalty is still not going to deter them from operating behind closed doors. (As we speak, CMS is considering moving forward with more stringent enforcement efforts and zeroing in on hospitals that have been egregiously negligent.) And certainly, at least in the early part of 2022, COVID continued to account for an overwhelming surge of patients, diverting the attention of hospital administrators and executives. But perhaps the real culprit is that despite the notable progress made, more has to be done to ensure hospital prices become crystal clear to the masses. Many a healthcare consumer still needs to plow through mounds of fairly cryptic data to effectively price-shop for an impending procedure or service.   </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""><span style="color:#1a1d26">“You have to find your plan, you have to find the procedure you think you're going to have, and you have to find the prices, and then you have to go to another hospital and pull up information there,” Lovisa Gustafsson, Vice President of the Controlling Health Care Costs Program at the Commonwealth Fund, was quoted as saying in the recent <i>U.S. News & World Report </i>piece. “It's not like they're side by side and you can easily compare them. You have to really seek this information out from every place. And so that makes it difficult. It's a lot of burden on patients to try to figure that out.”</span></span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span new="" roman="" style="font-family:" times=""><span style="color:#1a1d26">Will 100% of hospitals be fully transparent with their pricing metrics over the balance of 2023? Impossible to predict, but in the meantime, more Americans should be aware that they are entitled to request a hospital provide them with the price tag for a procedure—irrespective of whether the facility has already made such information readily available.</span></span></span></span></span></p> 1227