By Paul Boal, vice president of innovation, Amitech Solutions.
Consumerization has finally entered the healthcare realm. Patients and insurance payers don’t just want a good care experience from hospital systems; they want clarity in the form of price transparency. And they’re not the only ones.
Both the federal government and the Centers for Medicare & Medicaid Services (CMS) have set transparency expectations. Nonetheless, as The Wall Street Journal noted in December 2021, many hospitals have dragged their feet. And despite about 335 warnings from CMS, no hospitals have been fined, according to Fierce Healthcare reporting. However, it’s only a matter of time before consumer-centric healthcare and upfront hospital pricing data become the norm.
To be fair, it can be tough to get all hospital systems on the same page. Though CMS expectations ask for pricing data delivered via a comprehensive, machine-readable file, its directive has been interpreted differently by different hospital systems. There are nearly as many file formats as there are hospital systems publishing data. After all, hospital pricing can be complicated depending upon the patient’s needs, running the gamut from daily flat rates to rates based on the severity of the patient’s illnesses to bundled services that include special terms for quality of care.
Plus, the methodology for contracting and reporting will vary from one insurance payer to another. If a consultant uses bad or incomplete information to guide negotiations, the outcome can be less than accurate. For instance, our company has seen a large Arkansas provider network calculate different prices for a number of regional payers. How? It was publishing average prices, not contracted ones. This led to confusion and frustration for all stakeholders involved and required hundreds of hours of work to unwind and explain before real negotiations could take place.