Making Price Transparency Data Meaningful for Patients
This week Turquoise Health is officially launching Instant Good Faith Estimates (GFE), designed to provide pre-service estimates of cost when self-pay or uninsured patients schedule appointments. We’ll cover the importance of GFEs within the broader landscape of price transparency data and how we can get useful data into the hands of patients.
Let’s kick things off today with a trip down memory lane. January 1, 2021: Hospitals published payer-negotiated rates along with self-pay cash prices and shoppable service charges. July 1, 2022: Payers published all negotiated charges with hospitals and non-hospital entities such as ambulatory surgery centers, lab and radiology offices, and imaging centers. 2023 is the first year in the past few that, at the time of this blog’s publication, does not have any additional rate publication requirements on the horizon. You’re probably thinking, “Oh wonderful, maybe now they’ll start blogging about something much less buzzy than price transparency data, like politics or whether you can wear white after Labor Day.”
Well, we’re sorry to be the bearer of bad news, but other noteworthy rules and laws are at play this year, mostly centered on patient access to price and cost data.
In fact, as of January 1, 2023, payers are required to create a patient-facing estimation tool for 500 common items and services to give patients a clear idea of the cost of their care. This marks an interesting moment in the evolution of price transparency. Is January 1, 2023, the date the baton has been passed to patients to own their cost of care? In short, no, not yet. Payers and providers are still in the throes of creating accurate and timely pre-service estimates for both insured and uninsured patients.
Despite the technical and logistical delays, the tide is shifting from focusing solely on providers and payers to including meaningful takeaways for patients. After all, the patients are who the legislation, rules, and laws were written for! We know typical patients will not be attempting to open a machine-readable file, and we can neither confirm nor deny if the author of this blog spent minutes (or hours) opening one “just for fun.”
Only two hospitals have been fined for Hospital Final Rule non-compliance. That number must change if patient estimates are going to be impactful. Meaningful estimates are predicated on accurate, readable data, which at this point, has room for improvement.
Imagine a college professor who told students that there would be a 25% reduction in grade for every additional day a late assignment was turned in, only to give As on the first late homework assignments of the semester. As the semester continues, more and more students will likely submit delayed assignments because there’s no sense of urgency or fear of a penalty. Special shout out to the type A students who would have turned in assignments early, regardless, and are sweating profusely at the very idea of turning in a late assignment. We see you too.
Requirements are only as good as the subsequent follow-through with enforcement. Unenforced penalties do not motivate anyone dragging their feet to work quicker or improve habits, and this must change within the price transparency landscape in 2023. When federal and state governments clear that payers or providers who publish bad, incomplete, or no data are non-compliant and move to release a list of offenders, along with fines, we’ll see improvements in data quality.
Improved Data Interoperability
Creating accurate estimates before services are rendered poses a challenge to providers and payers, because claims are processed and adjudicated only after items and services have been finalized on a claim. *Inhale* In addition, procedures may require multiple clinicians and both professional and facility fees, and as a result, charges may come from different entities.
An industry-wide shift toward creating service packages before the appointment is essential to accurate up-front estimates. Those service packages can be created with improved data interoperability instead of relying on claims data after the episode of care. Shifting the assessment of items and services to before a visit and building infrastructure to translate the information into accurate estimates alleviates insurmountable burdens for both providers and patients.
As a start, Turquoise has published a beta release of standard service packages. These will directly tie in to the GFE requirement from the No Surprises Act (NoSA). As of January 1, 2022, providers who schedule uninsured or self-pay appointments (referred to as Convening Providers in NoSA) are required to share an accurate estimate within one or three business days after an appointment is scheduled, depending on how far in advance the appointment was created. Patients have access to a dispute resolution process if the final bill for items and services is $400 more than the GFE.
Turquoise has launched free Instant GFEs to assist providers with estimation creation and distribution. We’ll say that again for the people in the back: click here to sign-up for free Instant GFEs. If you’re a large hospital or health system with support and scale needs, we also have a paid version.
If you're the kind of person who needs to see it first, watch this:
Better Patient Education
Most patients expect that paying for an upcoming healthcare visit will be cumbersome, confusing, and expensive. If you’re reading this blog, it’s a safe assumption you’re working in the healthcare industry, interested in working at Turquoise (we’re hiring!), or trying to figure out what to do with a healthcare bill you disagree with. Having a snazzy yet informative healthtech blog is certainly a start, but ultimately, better patient education is a team effort that requires payers, providers, third-party innovators (present!), and the litany of others in the healthcare space to work together for the good of the patient.
You’d likely miss the chance to order a pair of your favorite shoes 50% off if you didn’t get an email or notification from the seller. For patients to request estimates, they need to know that 1) estimates exist, and 2) how to request and access those estimates. Spend five minutes looking at any website for any of these players in the industry, and you’ll see a patient-centric focus. In our humble opinion, patient-centric focus includes finding the highest mountain top and trumpeting helpful information related to transparency, cost of care, and estimates. Bonus points if you throw in a Miles Davis cover or two.
Sign up for Instant Good Faith Estimates here!