July 1, 2023: it’s been one year since the phrase “machine-readable fireworks” appeared on the Turquoise blog to commemorate both Independence Day and the go-live date for Transparency in Coverage (TiC)...aka, the day payer negotiated rates became publicly available! We’re happy to report it’s been a light and breezy yearlong journey from 0 parsed files → 531,095 parsed files. No major issues arose, price transparency data immediately landed neatly into the outstretched arms of every interested stakeholder, and we’ve basically been twiddling our thumbs for the past 12 months.

*cries into blog editor software

Ahh, if only. A more accurate summary is that payer rates crash-landed on the scene with all the grace of a hippopotamus attempting to turn a pirouette. We’ve done extensive documentation on the journey over the past year, so today’s focus will be a nostalgic look back, an assessment of the status quo, and some waxing poetic about what the future holds.

Impactful Numbers That Continue To Grow

A few months ago, Turquoise published an Impact Report that included a progress update on the payer data. We continue to see the data trending in the right direction as we approach the one-year mark. The updated graph below confirms a continued increase in the number of payers publishing data every month, and the June totals are projected to be the highest month to date! We are delighted to see a continued upward trend one year later.

The Number of Payers Publishing Data By Month

Our technical team continues to spend significant time working within our own metaverse, and while we haven’t built a completely alternate universe (...yet), we have continued to improve our metadata inventory. That inventory includes an increase in distinct provider disclosures across top payers.

Provider Category Reported by Payer

While we won’t be picking any favorites, you’re welcome to zoom in, screenshot, and dunk on your co-workers if you happen to be a part of the organizations listed above and happen to have more representation in one area of another.

The President Will See You Now

Price transparency has had many moments in the legislative sun this year. We’ve seen bills drafted, struck down, and passed at the state and federal level, all with much the same intent: to increase adherence and compliance to the Hospital Final Rule. The bills often focused on hospital MRF quality and completeness, clearly-displayed shoppable service prices, and protection for patients if they get bills from noncompliant hospitals.

You may have noticed that what’s quietly missing from the legislative discussions thus far has been audits or compliance updates on the payer files. If you ask us, which you kind of have, since you’re reading our blog, so thanks!, there are a few reasons this could be the case. First of all, TiC assigned enforcement ownership to the states. This differs from the Hospital Final Rule, which assigned enforcement to CMS. States tend to follow the lead of the federal government as far as where to focus new legislation, and the federal focus has been largely on hospitals.

Second of all, it’s not a secret that downloading, parsing, and comprehensively reviewing an entire state’s worth of multiple-payer MRFs is cumbersome and technically complex. As a general rule, compliance is only as effective as the enforcing entity’s ability to audit adherence to a requirement. Thirteen of the 20 words in that sentence started with a vowel.

That second reason hammers down the idea that metadata tables and data cleanliness can enable auditing and enforcement of the payer files. In the same way, we’ve seen an increased focus on hospital MRF quality, a government-led initiative to scrutinize payer files for completeness and accuracy holds insurers accountable for maintaining well-organized and useful files. Turquoise and others are actively working to provide a framework by which payer files can be analyzed and improved.

Patient Estimate Tools Want Their Own Section, Too

MRFs stole the spotlight for the majority of the second half of 2022, but another major component of TiC requirements has started having its own moment in the sun. Payers are required to host a patient estimate tool, to be released in two phases. Phase one, which went live on 1/1/23, required payers to support an estimating tool for 500 commonly shoppable procedures. Coming up on 1/1/24, the floodgates open and the estimate tools are required to support estimates for all items and services.

Generally the word “all” is shudder-inducing because…well…“all” certainly applies to a lot. “All” also tends to conjure up edge cases out of the woodwork. For example, if a psychiatrist is in a network with a payer who reimburses based on a fee schedule, and that fee schedule includes rates for foot surgeries, would the patient estimate tool for the psychiatrist need to include those foot surgery rates? If the directive to include all negotiated rates is taken literally, then yes.

Realistically though, the psychiatrist probably doesn’t even have a scalpel laying around for any type of surgical intervention, so it’d be highly unlikely that a patient would need to know the payer-negotiated rate. So who benefits from the inclusion of such rates in an estimate tool? Does including them cause more harm than good, if the result leads to clunkier estimate tools, confused patients, or even psychiatrists hesitantly scrubbing in to perform surgery on a bunion?

This is a key sticking point that hospitals did not have to assess, because their price transparency requirements were built off all items and services specifically within the hospitals’ charge data masters (CDM). Those CDMs ended up serving a crucial purpose by minimizing unlikely procedure/physician combinations, like the example laid out above. CDMs also set defined parameters for what items and services should be included. Technical projects operate much, much more efficiently within defined parameters than more nebulous tasks. From that perspective, the difference between “all items and services in the CDM” and “all items and services” is enough to age a person several decades.

Payers do not maintain a CDM, but they do maintain claim data repositories for every provider they’ve processed claims on behalf of. A possible solution would be a clarification to TiC that the patient estimate tool must support all items and services billed from a specific provider or facility over a defined number of months. To ensure all new items or services for which a provider begins billing appear in the estimate tool, payers could be required to update the underlying claims data repositories the estimate tools are built atop monthly or quarterly.

Long term, though, simpler billing practices are a more sustainable solution. Turquoise continues to make progress on our Standard Service Packages (SSPs), which remain in a free, open-source library. We have over 200 SSPs available, and as more SSPs are created, fewer billing codes are required to maintain an accurate estimate tool. This simplification stands to be a major shift in proving patients can and should be able to confidently assess costs of care prior to an appointment occurring. If you’re reading this and want to nerd out more, SSPs are available for feedback on a Github repository.

As We Go On, We Remember

And with that, we raise our glass to you, payer data! Thnks fr th mmrs. Here’s to another year of metadata tables, patient estimate tool improvement, and an unwavering commitment to increasing the usefulness and impact of price transparency data.

Want to celebrate this momentous occasion with a gander at the data? The data is accepting anniversary gifts sent to info@turquoise.health.