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The amount the health insurance company pays for care is about to be published: Shot

The new rules will help people get an upfront cost estimate for about 500 so-called “shoppable” services. This means medical care that can be scheduled in advance.

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The new rules will help people get an upfront cost estimate for about 500 so-called “shoppable” services. This means medical care that can be scheduled in advance.

DNY59 / Getty Images

Consumers, employers, and almost anyone else interested in health care pricing will soon get an unprecedented view of how insurers pay for care.

Start-up July 1, Health insurance companies and self-insurance employers should post item-by-item websites for almost all prices negotiated with health service providers. The only exclusion is the price paid for prescription drugs, except those given in hospitals and clinics.

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The release of data required by the federal government can affect future prices and even how employers contract for health care. For the first time, many will see how well their insurance company is doing compared to other insurance companies.

The new rule is much broader than the rule that came into force last year, which requires hospitals to post negotiated fees so that they are visible to the general public. Currently, insurance companies need to post the amount paid to “all doctors, all hospitals, all surgical centers, all nursing facilities in the network”. Jeffrey Reybach,Of partners Consulting company guide house.

“When you start math, you’re talking trillions of records,” he said. The fines that the federal government can impose on violations are also heavier than the penalties faced by hospitals.

Federal authorities learned from Hospital experience Reybach said he gave more direction to what insurers are expected to do. Insurers or self-insurance employers may be fined up to $ 100 per day for each breach and for each affected registrant if they do not provide the data.

“Take out the calculator. Suddenly, millions of people get pretty fast,” Reybach said.

Resolute consumers, especially those with high deduction health insurance, need to dig deeper and use the data immediately and pay for specific services at different hospitals, clinics, or clinics. You may try to compare a certain amount.

However, the very large size of each database may mean that most people “feel very difficult to use the data in subtle ways.” Catherine BakerDean of the University of Chicago Harris School of Public Policy.

At least at first.

Entrepreneurs are expected to be able to quickly transform information into a more user-friendly format and incorporate it into new or existing services that estimate patient costs. Also, after January 1st, insurers will need to provide online tools to help them get upfront cost estimates for about 500 so-called “shoppable” services. This means medical care that can be scheduled in advance.

When these things happen, “at least there are choices in front of us,” said Chris Severn, CEO of. Turquoise healthAn online company that publishes pricing information based on hospital rules, but many hospitals are not yet compliant.

Adding insurer data allows sites like him to dig deeper into cost fluctuations from one location to another, or between insurers.

“If you want to shoot X-rays, you’ll find that you can shoot at this hospital for $ 250, at a future imaging center for $ 75, or for a specialist for $ 25 in the office,” he said.

Everyone will know the business of others. For example, how much Aetna and Humana will pay to the same surgical center for knee replacement.

Requirements come from the Affordable Care Act and 2019 Presidential order According to then President Donald Trump.

“These plans are to act on behalf of employers in negotiating good rates, and a little insight we have about it shows that it didn’t happen.” Said Elizabeth Mitchell, President and Chief Executive Officer of the Buyer Business Group on Health, the affiliation of employers who provide work-based health benefits to workers. “I believe the dynamics will change.”

Other observers are more cautious.

“Maybe this will, at best, reduce widespread fluctuations in prices there,” he said. Zack Cooper, Director of Health Policy Department, Institute of Social Policy, Yale University. “But that doesn’t unleash the consumer revolution.”

Still, the greatest value of the July data release may be to reveal how successful insurers are in price negotiations. It comes shortly after studies that have shown tremendous changes in what is paid for health care. A Recent research For example, according to Rand Corp., employers offering work-based insurance plans paid an average of 224% more than Medicare for the same service.

Tens of thousands of employers who buy insurance for their workers will get a complete picture of this more complete pricing — and may not like what they see.

“What we’re learning from hospital data is that insurance companies are really bad at negotiating,” he said. Gerald AndersonJohns Hopkins Bloomberg, a professor of health policy at the Graduate School of Public Health, said hospital care negotiation fees can be higher than what the facility accepts from patients who are not insured and are paying cash. I am quoting the research that I found.

It can increase the frustration that employers have with their current health insurance system, as Mitchell and others. Some may try to contract directly with their provider, using the insurance company only for claim processing.

Other employers can bring the insurance company back to the negotiating table.

“For the first time, the employer goes to the insurance company and says,” You are not negotiating enough deals. We know that the same provider is negotiating a better deal with another company. . ,'” Said James GelfandChairman of the ERISA Industry Commission, an industry association for self-insurance employers.

If that happened, he added, “Patients will be able to save money.”

However, it is not always given.

The disclosure of this type of price data has never been widely attempted in healthcare, so it is unclear how it will affect future spending. Prices can go down if insurers are pushed back to the negotiating table or providers see where they stand compared to their peers. However, some providers can raise the price if they decide that the price is cheaper than their peers.

“No downward pressure may be given,” he said. Kelly SchultzVice President of Trade Policy at AHIP, the industry’s trade lobby.

Baicker of the University of Chicago said that even after the data was released, prices would continue to be heavily influenced by local conditions, such as the size of insurance companies and employers. For example, insurance companies often offer large discounts to insurance companies. Or a self-insurance employer who can send them the most patients. The number of hospitals in the area is also important. For example, if there is only one in a region, it usually means that the facility can request a higher rate.

Another question: Do insurers meet deadlines and provide usable data?

AHIP’s Schultz said the industry is on track, partly because the initial deadline has been extended by six months. She expects insurance companies to be better than the hospital industry. She said, “There were many hospitals that decided not to post files or make them hard to find.”

To date, more than 300 non-compliant hospitals have received warning letters from the government.But they can face a fine of $ 300 a day Federal government recently Raised the ante Up to $ 5,500 One day for the largest facility.

“I don’t think things will change overnight,” Reybach said, even after the price data was released. “Patients will still make care decisions based on doctors and referrals for many reasons other than price.”

KHN (Kaiser Health News) is a national news room that produces detailed journalism on health issues. This is an editorial independent operating program. KFF (Kaiser Family Foundation).

The amount the health insurance company pays for care is about to be published: Shot

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