Trepidation about transparency (in healthcare prices)? Take a closer look.

The recent Executive Order regarding health care price transparency has many folks in the health care industrial complex contemplating litigation aimed at highlighting ways in which the order may contravene existing law. It is also unpopular because list price transparency may well have the opposite of the desired effect — it may increase prices in certain circumstances rather than reduce them.

See my post on the health care pricing transparency Executive Order, and my recent Inside Digital Health column on the same topic. In a sense, the key thing to consider is that we all want to know what our bottom-line cost of health care services will be, specific to our own health plan, and our own provider. There are tools out there that can deliver this information, and the pity is that more provider organizations don’t use them. Doing so could improve customer / patient satisfaction immensely.

The administration seems to be trying to get a jump on pending congressional activity in this realm and delivering some version of transparency. In the process, the administration is garnering support from some patient advocates and generating opposition by some associations representing payers and providers.

If you are experiencing a little déjà vu, that’s understandable; the idea of making price and quality data about “shoppable” healthcare services easily available to all is by no means new. Transparency, on its face, seems like it must be a good thing. Alas, nothing is that simple. The key issues, now as always, include at least two key categories of questions:

1. Are the requirements legal? The principal issue here (assuming we get over the question of scope of executive authority and conflicts with existing law), is whether the requirements are anticompetitive or procompetitive. For example, will mandating the release of price data result in all prices for a given service rising to the level of the highest price for that service disclosed in any given market?

2. Would compliance yield meaningful data to consumers, enabling informed decision-making about healthcare services and providers? In other words, will cost and quality measures be linked in a manner that is accessible to and understandable by typical consumers? Will the information be shared in a user-friendly format, through a user-friendly channel and in a user-friendly manner?

Transparency is a hot topic, and my most recent podcast addressed the same issue from a different perspective.

Read more here.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Jeanne Pinder, CEO of Clear Health Costs – Harlow On Healthcare

I am pleased to host Jeanne Pinder, founder and CEO of Clear Health Costs (@chcosts). An accomplished journalist with over two decades of experience with The New York Times. Jeanne founded Clear Health Costs to bring transparency to the health care marketplace and empower consumers to make informed decisions about their health care. Clear Health Costs has partnered with news media outlets in different markets around the country to help shine a light on health care services pricing garnering awards and further coverage for its work. In addition, Jeanne’s TED talk on health care price transparency has garnered well over one million views.

Listen live at 8:30 AM, 4:30 PM or 12:30 AM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #HarlowOnHC.

Like many innovators on a mission to fix healthcare, Jeanne’s introduction to the funhouse of health care pricing was through personal and family experience, including a time

when I was being charged $1,419 for a generic anti-nausea drug that I could buy online for $2.49. I had this long and unsatisfying argument with the hospital, the insurance company, and my employer. Everybody agreed that this is totally standard. Nothing out of the ordinary. The more I thought about it, the more I talked with other people, I realized that nobody has any idea what stuff costs in health care. You don’t know before, during or after that procedure what it will cost. Only months later do you get a bill or an explanation of benefits … that explains exactly nothing.

Jeanne believes that it is important for everyone to be bale to comparison-shop for “shoppable” health care services.

Most people don’t really know that prices vary so much. We assume that prices are somehow fixed or regulated or that they don’t vary quite that much. And yet increasingly people are learning they do vary by a lot.

She is concerned that even insurance company price calculators are not all that accurate because of a built-in bias, where insurance companies may have an interest in steering patients to preferred providers. Jeanne notes that state all-payor claims databases are not all that useful. And some companies connect patients with providers by displaying prices and taking some compensation for connecting patient and provider (a la Kayak or Amazon Marketplace). But “at Clear Health Costs, we’re journalists; we’re not steering people anywhere.”

I asked Jeanne if she has been able to add quality metrics to the comparison shopping data on Clear Health Costs, but she bemoans the lack of truly useful quality measures at the micro level, noting that “if we found a good quality metric we would incorporate it yesterday, because people don’t really want the cheapest appendectomy…. They want good value.” She says quality transparency is as broken as price transparency and so we are left asking neighbors and co-workers and Facebook friends for recommendations.

We shared our frustration at the lack of reliable quality reporting, and with the way in which many hospitals have implemented compliance with pricing transparency regulations (machine-readable, but incomprehensible to mere mortals, chargemaster prices for specific services, by billing code). The price transparency rules are difficult as well, since nearly nobody pays “list price” for health care services.

Jeanne said:

I would stand back and applaud if the hospitals were required to publish not only their chargemaster prices but juxtapose those prices next to the Medicare reimbursement rate (which can be a tenth of the chargemaster price), juxtaposed with the cash price for that same procedure and also the negotiated rates with major insurance companies — Aetna, United Healthcare, Cigna, Blue Cross.

In the time since we spoke, the price transparency executive order has issued, though it remains to be seen whether it will be challenged by industry, and how it is ultimately implemented, if at all.

When I asked Jeanne what she would hope to see five years from now, she replied that she hopes she will have put herself out of business, by succeeding in revealing costs and in encouraging health care consumers to insist on price transparency more broadly.

Meanwhile, Jeanne notes that in a Pew Research poll, 83% of Americans said that high costs were keeping them from getting health care, and that in a CBS poll preceding the midterm elections, 66% of Americans said that health care was their top issue.

We talk to people who can’t afford their medication, who have to choose between paying for health care and paying the mortgage.… Imagine knowing that you can afford the diagnosis and not the cure. This is an untenable situation. It cannot continue.

I spoke with Jeanne as part of my ongoing series of fireside chats with healthcare innovation leaders – Harlow on Healthcare, on HealthcareNOW Radio. Listen to our radio station online, or ask your smart speaker (Amazon Echo or Google Home): “Find Tune In station HealthcareNOW Radio.” You can catch me live weekdays at 8:30 am, 4:30 pm and 12:30 am ET. As each new show goes live, the last one joins the archive, available via SoundCloud or your favorite podcast app (iTunesStitcheriHeartRadio). Your comments are welcome here. Join the conversation on Twitter at #HarlowOnHC.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Photo credit (Jeanne Pinder): Andy Kropa

A step in the right direction for telemedicine: Medicare Advantage

A recently-finalized rule implements a significant telemedicine expansion for Medicare Advantage plans. (See presser, fact sheet, and final Medicare Advantage telemedicine rule.) Telemedicine or telehealth benefits may now be included in core Medicare Advantage plan benefits, not just offered as supplemental benefits.

In the first edition of my column for Inside Digital Health, I wrote about this news and some implications for the healthcare provider community seeking to use this change to better serve the Medcare Advantage market.

Excerpt below; follow the link for the full piece, Medicare Advantage Telehealth Rule Could Be Big for Health Systems.

Medicare Advantage plans are being given broad discretion in implementing this expansion.

The effect that this change is likely to have on the prevalence of real-time video-linked telemedicine (so-called “synchronous telemedicine visits”), as well as on broader telehealth services, should not be underestimated.

Medicare Advantage plan members represent a growing percentage of Medicare beneficiaries. The most recent figures show that, of the 64 million Medicare beneficiaries today, 22 million are Medicare Advantage members. This represents the culmination of a steady increase both on a percentage basis and on an absolute basis over the past 20 years. Within the Medicare population, telemedicine has slowly but surely gained traction over the years, with rural telehealth visits increasing over 25% per year in the decade ending in 2013. As the ranks of Medicare Advantage members come to include more and more folks comfortable with transacting everything in their lives via their smartphones, tablets and laptops, the opportunity for the healthcare delivery system to provide more interaction via telemedicine continues to grow.

Read the full piece here.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Cost transparency – The next grand experiment in healthcare

Much has been said about cost transparency in healthcare, and this week, the administration got slightly more specific, issuing an Executive Order calling for some regulations and reports:

The Federal Government aims to eliminate unnecessary barriers to price and quality transparency; to increase the availability of meaningful price and quality information for patients; to enhance patients’ control over their own healthcare resources, including through tax-preferred medical accounts; and to protect patients from surprise medical bills.

The order directs agencies to issue proposed regulations, first on price transparency for hospital prices (NB: while garnering much attention, hospital costs account for just 1/3 of the total healthcare spend), and then more broadly out-of-pocket expenses for beneficiaries of employer-sponsored and other health plans. Next, HHS, the AG and the FTC are supposed to issue a report

describing the manners in which the Federal Government or the private sector are impeding healthcare price and quality transparency for patients, and providing recommendations for eliminating these impediments in a way that promotes competition.  The report should describe why, under current conditions, lower-cost providers generally avoid healthcare advertising.

Next up is rationalizing health quality emasures across federal agencies, and then working on identifying claims data that should be made more widely avialble and then de-identifying them and releasing them.

The order then moves on to direct expansion of HDHP/HSA combos “that cover low-cost preventive care, before the deductible, for medical care that helps maintain health status for individuals with chronic conditions.”

Next up is a super-vague provision directing regulatory development ot make “expenses related to certain types of arrangements” deductible medical expenses. Examples given include direct primary care and health ministries but, again, as written, the provision is extremely vague.

Wrapping it up, there’s a nod to rolling over FSA balances and to getting a report from HHS on surprise billing.

There’s a lot in there; some is pretty vague, and some is more specific. In any event, there is likely to be significant pushback from the regulated community (even those who from time to time seem to embrace change) once these rules start making their way through the sausage factory.

For an Administration that has promised a terrific healthcare plan time and again, this smattering of somewhat positive-sounding calls for action is sort of anticlimactic, but it is not unexpected, given the state of divided government.

Setting aside the question of releasing proprietary or confidential information for just a moment, the challenge for the industry is to consider which of the price transparency initiatives it may wish to tackle even before the regs come down the pike, or what sorts of alternatives to consider, in order to improve customer relations.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Nick VanDuyne, RHIOs and the SHIN-NY — Harlow On Healthcare

I spoke with Nick VanDuyne, Executive Director of the New York Care Information Gateway, a regional health information organization (RHIO) operating in the New York City and Long Island region. RHIOs have had a bumpy ride in general, and not many have been able to find a sustainable business model. The NYCIG is one regional component part of the State Health Information Network of New York, aka the SHIN-NY (yes, it’s pronounced “shiny”). There are actually three RHIOs in the New York City area, given the population density, and several more spread out across upstate New York. The SHIN-NY is supported by state appropriations thus far, which has allowed it to mature without facing the financing challenges that so many other similar enterprises have faced. That day of reckoning is likely to come in the not-too-distant future, but, as I discussed with Nick, the SHIN-NY may be well-prepared for that day given its diverse value propositions for its various constituencies.

So what is the SHIN-NY, really? As Nick says,

[The SHIN-NY is] really the core piece that allows all the RHIOs to speak to each other. We have the ability to transact data from one area to another. And we have the ability to move clinical event notifications throughout the entire state regardless of where a patient shows up. That’s, again, facilitated by the SHIN-NY, and the fact that we have a master patient index at the state level that we all contribute our patient identifiers to.

In addition to the consolidated CCD information that one might expect to see coming through a RHIO, a provider can subscribe to ADTs for particular patients anywhere in the state and receive them in real time. This allows for better statewide care management efforts than may be available in many other parts of the country. (Commonwell and CareQuality do not offer this functionality.)

The overall infrastructure is funded by the state, and local connections are the responsibility of each participating institution. But state funding is slated to run out at the end of March 2021, at which point the SHIN-NY and the RHIOs will likely have to face the music, and justify the costs to their constituencies or risk obsolescence.

Nick described some of the SHIN-NY’s use cases, which he thinks will offer a cost-effectiveness justification for continued funding.

As one example, the SHIN-NY allowed clinicians to pick up the trail, so to speak, of thousands of patients – in one particular cohort, tracking hemoglobin A1C levels of nearly 10,000 patients without the need for incurring the cost of staffing up a care coordination program, and ultimately tracking forty discrete data elements for a plan with a patient population of about 20,000, and closing up gaps in care and yielding improved value-based payments.

Other diseases and chronic conditions may also be better managed using the tools at the RHIO’s disposal (e.g., CHF, COPD, pediatric asthma).

While there is recent movement inside the Beltway away from continuing the ban on federal dollars for development or implementation of a UPIN, NYCIG has started using innovative patient matching tools that have allowed it to eliminate 500,000 duplicate patient records (and that’s a significant portion out of a total of seven million patients). This allows for improved patient tracking across care settings, which allows for sharing clinical event notifications from one health system to another (since the density of providers is so high in NYCIG’s geography, and patients tend to receive care at multiple providers). One pilot project saw an increase in readmission avoidance payments on the order of 300%.

These examples and others all speak to the tremendous potential of the SHIN-NY, and it seems that its future should be secure, given the tremendous improvements in care coordination and reduction in costs that this health IT network has brought to New York State.

I spoke with Nick as part of my ongoing series of fireside chats with healthcare innovation leaders – Harlow on Healthcare, on HealthcareNOW Radio. Listen to our radio station online, or ask your smart speaker (Amazon Echo or Google Home): “Find Tune In station HealthcareNOW Radio.” You can catch me live weekdays at 8:30 am, 4:30 pm and 12:30 am ET. As each new show goes live, the last one joins the archive, available via SoundCloud or your favorite podcast app (iTunesStitcheriHeartRadio). Your comments are welcome here. Join the conversation on Twitter at #HarlowOnHC.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

You Had One Job, or, If you can’t ensure data security, then ….

Vibrent, one of NIH’s data management contractor for the All of Us genomic and other health data research project, was found by OIG to have a number of holes in its data security infrastructure and policies, ranging from failure to encrypt its AWS servers to failure to adhere to FISMA (federal IT security) standards more broadly. OIG also found that NIH fell down on the job by not monitoring its contractor more closely. Everything has been patched, but this represents a black eye for a program intended to build public confidence in government colleciton and analysis of sensitive medical and genomic data as it seeks to enroll one million Americans.

What can NIH, or any entity responsible for dealing responsibly with sensitive medical, genomic or other personal data, do to discharge its responsibilites more adequately?

As regular readers of HealthBlawg are already rehearsing silently, it’s all about infusing a compliance mindset into organizational culture. This, combined with practical tools and empowerment of personnel, will then manifest itself in comprehensive data privacy and security policies and procedures, function-specific appropriate training and testing of personnel, compliance review of subcontractor organizations, personnel and technical infrastructure in advance of engagement, regular audits of subcontractors’ activities and deliverables from a data security perspective, and more. Many of these ideas are spelled out in the federal standards applicable to this procurement, but somehow they didn’t make it to the front lines.

The All of Us program has taken long enough to get off the ground, and is taking baby steps towards its enrollment goals. Here’s hoping that this misstep does not squander the momentum the program has built to date.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting