Springtime at Turquoise Health can mean one thing and one thing only: April showers and May flowers A new product feature designed to gauge compliance with a specific requirement within the 2024 Hospital Final Rule. We know that’s exactly what you were thinking as well.

The upcoming 7/1 requirements are top of mind, but a few less splashy requirements went live back on 1/1/24. Those January requirements were not about the contents of the MRF, but rather where files are located on hospital websites. Turquoise Co-Founder and CEO Chris Severn has frequently referred to finding MRFs as “the world’s worst Easter egg hunt” and he’s not wrong. An informal poll of employees confirms we’re ready to move on from egg hunt metaphors. New quarter, new challenges.

From the 2024 Final Rule, as of January 1st, hospitals must have posted:

A .txt file in the root folder that includes:

  • The hospital location name that corresponds to the MRF
  • The source page URL that hosts the MRF
  • A direct link to the MRF (the MRF URL)
  • Hospital point of contact information

A link in the footer on its website, including but not limited to the homepage, that is labeled “Price Transparency” and links directly to the publicly available webpage that hosts the link to the MRF.

This blog focuses on that first .txt file requirement. We’ll outline our processes for gathering info and share a preliminary state of affairs. Are hospitals creating the .txt files as required? Has anyone else been whistling the theme from The X-Files since they started reading this blog?? Let’s find out.

Shades of Compliance

There have always been certain components of price transparency compliance that are difficult to measure on anything other than a spectrum. For example, how do we know exactly how many negotiated rates a hospital or payer has? And, if we do know the exact number, where do states or The Center for Medicare and Medicaid Services (CMS) set the cut-off for chasing down missing rates? Let’s say a hospital has 8,500 negotiated rates and they post an MRF that displays 8,462 rates. Keeping in mind that one of the goals of price transparency as cited in the 2024 Final Rule is to allow consumers to shop for care, do those missing 38 data points derail the industry?

Much has been documented about the challenges of auditing and enforcing compliance on a spectrum with the Hospital Final Rule that went into effect on January 1, 2021. Pick your favorite reason and say it with me: no required schema, files must be placed in an “easy to find location,” etc. All that translated into the inability to create binary checkpoints of compliance. Did a hospital post an MRF, and was it easy to find? How many clicks into a website does “easy to find” entail? Or, hearkening back to the paragraph above, does the MRF contain all data points for the five types of standard charges? That last question starts to get hairy, because “all” is difficult to define.

In the 2024 Final Rule, CMS commented on this exact scenario:

“... because hospitals are permitted to display their information using a wide variety of file formats and data encoding practices, we must manually, via time and resource-intensive processes, review the information in the files to assess whether the information is consistent with the data element requirements…We, therefore, came to believe that requiring more specificity in formatting and encoding the MRFs, as well as increasing the number of required corresponding data elements that hospitals must provide, would not only create efficiencies for public users of the MRFs and our efforts to enforce the requirements but also improve the meaningfulness of the hospital’s standard charges.”

Essentially, because each hospital MRF is a snowflake, assessing compliance quickly became to be a one-MRF-at-a-time process.

Binary Compliance Assessments

The 2024 Final Rule aims to move assessment and compliance in a much more binary direction. The more binary the process, the stronger CMS’ overall assessment and compliance efforts can be. On any given day, a number of stakeholders ask the question, “Are hospitals complying with the Final Rule?” Journalists, hospital associations, the government, payers, innovators, and patients as consumers all want a clearer answer, and, ideally, for that answer to be “yes.”

Turquoise views some components of the 2024 requirements as a series of yes/no checkpoints along the road to MRF El Dorado, that, ideally, when hospitals reach their end destination and publish their files, the MRF generation teams, as well as any interested observers, will have confidence knowing the file was built and displayed as required. To bring that checkpoint to life, Turquoise has launched a handy module that allows anyone and everyone to get a clear “Yes” or “No” indicator regarding whether or not a hospital has correctly adhered to .txt file requirement.

Screenshot of a hospital's profile on the Turquoise platform. You can see from the info shown on the left column that the hospital's MRF location file is present.

You can find out how your hospital of interest did by searching for it here.

As with any assessment tools we make, the Turquoise Health Elle Woods is quickly interrupting the regularly scheduled blog with a PSA that Turquoise Health is not the government-appointed arbiter of price transparency compliance. Only CMS can deem an organization compliant or noncompliant with requirements. Our intention with reporting on required criteria adherence is to share data-driven findings for industry review.

Now, back to the program!

Checkpoint 1: The .txt-Files

CMS has made good on its promise within the 2024 Final Rule to continually add to and hone its resource repository for hospitals to utilize as they update their processes based on the new requirements. That repository includes a .txt file generator. The generator is designed to generate (obviously) an output hospitals can copy/paste for their MRF publication; however, it does not assess whether or not hospitals are actually using the .txt files on their websites as required. So with the generator in hand, we asked ourselves, “Are hospitals uploading their .txt files? And are they doing so correctly?”

To answer these questions, we built a process for ingesting .txt files around the following four steps:

  1. Begin on the hospital's website. For this example, we’ll use Honor Health Deer Valley Medical Center. The website is: https://www.honorhealth.com/locations/hospitals/deer-valley-medical-center
  2. Strip the link for this hospital down to its root URL. Again, in this case: www.honorhealth.com
  3. Add the suffix “/cms-hpt.txt” to the root URL, in search of the required .txt file at its correct location. In this case, the result would be: www.honorhealth.com/cms-hpt.txt
  4. Ingest this data and map the locations displayed in the file to our database of hospitals. When we find a match, we give the hospital a ✅ indicating that their MRF Location File is present!

Here’s an example of that process:

Here's an example of the .txt file ingestion process

Wherefore Art Thou, .txt Files?

Of the over 5,900 hospitals from which we’ve ingested MRF data, we’ve located more than 1,800 .txt files. That translates to roughly 30% of hospitals following the .txt file requirement. We sliced and diced that data in a few different ways:

  • 82% of the hospitals (1,470) that have followed the guidelines belong to health systems
  • 15% of independent hospitals have posted correct .txt files

Now that we’re one quarter into the new requirements, it’s reasonable to expect adherence to be higher than 30%. So what’s up with the numbers? It could be that some hospitals are waiting until the 7/1 deadline to get their files up to snuff in one fell swoop; however, they risk receiving a CMS letter of noncompliance in the interim.

In addition, we did notice some .txt files that earned the “Almost, but not quite” distinction. Common themes among them:

Health systems published multiple hospital names as a comma-separated list under “location-name” for a single element.

  • While this seems to make logical sense, if a single file pertains to multiple hospitals, the Final Rules states the health system must post individual elements for each hospital and repeat the mrf-url each time.

Cases where the headers of the TXT.txt elements didn’t quite match the CMS format. As an example:

  • Hospital location name that corresponds to the MRF: Test Hospital West
  • Source page URL that hosts the MRF: https://hospitalhealth.net/locations/hospitals/source-page-url
  • Direct link to the MRF: https://hospitalhealth.net/standardcharges.csv
  • Hospital point of contact:  Office |123-867-5309|                                       email |Office@hospitalhealth.net

We recommend using the CMS tool and copy/pasting the results. It’s the open book, open notes portion of the exam and we suggest leaning all the way in. Or, if hospitals are looking for a partner, like Turquoise, to create MRFs, all parties involved can be confident the .txt file has been worded correctly.

In a binary assessment though, there is really no third option for the outcome when a hospital “didn’t quite match the required format.” Shades of grey don’t allow for peace of mind and assurance of full compliance, and the goal of our validator module is to give the teams creating and posting MRFs a high confidence level they’ve done so to the letter of the law.

That’s part of the draw of building a binary review module: ideally, hospitals utilize this feature to confirm they completed what’s required to a T.

The Health Systems Challenge

The stats above also point to some benefits that larger health systems have access to. Specifically, they may have larger teams working on MRF generation, rates that apply to numerous hospitals, or better technology for pulling all the required data elements. However, even though more health systems posted .txt files when compared to independent hospitals, we're still seeing some gaps.

We specifically looked into .txt file publications from large health systems with 10 or more hospitals. What we found was 64% of those health systems published a .txt file for at least one of their hospitals. That seems to indicate an awareness of the requirement and at least an initial effort to comply. On the other hand, only 1.9% of those same large health systems posted files for every single one of the hospitals in their system.

A number of questions arise from this data. Is a centralized team responsible for posting all its systems’ hospital MRFs? Or, if a health system has hospitals in numerous states, is the responsibility divided among various CBOs or even to each specific hospital?

And, perhaps most importantly, are these health systems setting themselves up to hit the next two checkpoints from the 2024 Final Rule on 7/1 and 1/1/25? At the time of publication, CMS has not issued a civil monetary penalty (CMP) for price transparency noncompliance since 9/27/23, so it’s possible hospitals and health systems did not feel a sense of urgency. They may be content to bake in the requirements from the 1/1 deadline as they work toward the 7/1 deadline.

We saw hospitals shore up their files after a flurry of CMPs earlier in 2023, and that may be what occurs later this year. Ideally, though, hospitals work through the new requirements in waves, as intended by the 2024 Final Rule, and we start to see the number of correct .txt files steadily increase in the coming months.

.txt Or Bust

Why even bother taking this journey to .txt El Dorado? As always, we believe that accurate and comprehensive MRF data is foundational toward getting upfront cost of care to patients. In order to validate rate data, the MRFs first and foremost need to be easily located.

Plus, as MRF generators ourselves, the best accountability we can point to is that our own files must also meet every CMS compliance requirement. Building the .txt file validator module is the first in a series of checkpoints we’ve designed to bring the industry real-time compliance indicators.

Want to discuss your own hospital’s .txt file? Or anything else related to MRF generation? Send us a message!