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More than two-thirds of National Cancer Institute (NCI) cancer center-designated hospitals have yet to meet the Centers for Medicare & Medicaid Services (CMS) hospital price transparency standards, per a Pacific Coast Surgical Association research letter published in JAMA Surgery.
The CMS price transparency rules finally came into force on July 1, 2021, after a series of delays caused the enforcement date to be pushed from the initial January 1.
As dictated by the new healthcare price standards, healthcare providers and all hospitals, including NCI-designated cancer centers, must publish machine-readable files indicating both insurer-negotiated and gross charges for 300 standard services rendered to the patients.
More specifically, the price information should be listed in a format that is user-friendly and freely accessible without the requirement of signing up or logging in. More than that, all CMS price listings should be correctly named, include any relevant covered items, and indicate the services offered in a machine-readable format.
Together with the No Surprises Act, the CMS price-disclosure rules were designed explicitly to help patients understand the charges associated with covered services or items before the doctor’s appointment. As a side benefit, the price transparency regulation will help curb the runaway predatory billing practices.
Unfortunately, multiple investigative studies and surveys carried out since the CMS price transparency regulation went into effect have found that hospitals – especially those in large managed networks – have yet to fully comply with the requirements.
In response, the Biden-Harris administration passed a regulation in early November 2021, essentially increasing the maximum punitive penalty from $109,500 to as much as $2 million per hospital for large hospitals that fail to comply with the CMS price-disclosure rules, according to Wall Street Journal.
Despite these sharp punitive measures, hospitals are still dodging the price transparency rule requiring them to make what they charge patients public, and it seems cancer centers are no different.
For the study, experts at Pacific Coast Surgical Association analyzed the websites of sixty-three NCI-designated cancer centers to identify the facilities that have published their negotiated charges in compliance with the CMS price transparency rule.
The researchers checked whether the hospitals in question had complied with five critical federal price transparency requirements.
The first thing they looked at was whether the uploaded files were (i) freely accessible in a machine-readable format without the need for the user to provide personal information or register, (ii) comprised a list of services and items the center offers, and (iii) named correctly.
On top of that, the research team made sure to check whether each service or item in the list incorporated essential pricing elements, such as discounted cash price, de-identified maximum negotiated charge, de-identified minimum negotiated charge, payer-specific negotiated charge, and gross price.
The JAMA study’s most central finding was shocking yet unsurprising to the researchers: while 42 (or about two-thirds) of the 63 hospitals analyzed in the survey published some information on discounted cash prices and negotiated charges, only 20 (or less than a third) were in full compliance with the CMS price transparency requirements.
Close to 16 percent of the hospitals surveyed in the study failed to comply with all five federal price requirements.
Failure to publish files in a consumer-friendly, machine-readable format was the most commonly violated of the CMS price transparency rules among hospitals with NCI-designated cancer center status. 12 hospitals failed to adhere to this requirement.
The same JAMA study revealed that the majority of files and websites of NCI-designated cancer centers were neither user-friendly nor easy to navigate.
Researchers found that many files containing critical pricing information were huge, with most running to several gigabytes. The files were also technically dense, requiring coding expertise and advanced skills to open and grasp.
Besides, some files contained tens of thousands of rows of data and were not organized for easy browsing based on the insurers or services listed.
According to the JAMA study, hospitals with clinical cancer center status were less likely at 33 percent to comply with hospital price transparency rules than their comprehensive cancer center-designated counterparts. Seventy-four percent with the latter designation were compliant.
Fifty-seven percent of cancer centers in the South had fully complied, while hospitals in the West boasted the highest compliance rate of 86%.
Researchers studied the maximum and minimum payer charges for 3 key diagnosis-related groups (DRGs), namely pancreas cancer, colon cancer, and esophagus/stomach cancer.
Keeping track of DRGs is a crucial part of preventive health care that can help further drive costs and lower insurance premiums. Besides, DRG coding errors are some of the leading and most costly medical billion offenses, according to Healthcare Weekly.
Only 24 to 29 percent of surveyed hospitals list payer-specific charges for procedures related to these DRGs.
Additionally, the study found considerable differences in maximum and minimum rates for various payers across and within the hospitals for the operations associated with these cancers.
Interestingly, there were notable price variations among NCI-designated cancer centers that provided sufficient pricing info and complied with the CMS hospital price transparency requirements.
The latter finding seems to suggest that the CMS regulation may have achieved its primary objective of driving down prices and ramping up competition among facilities with NCI-designated cancer center status.
Nonetheless, the regulation has faced low compliance among hospitals since it took effect in 2021. That’s where Turquoise Health and Ribbon Health come into play.
Ribbon Health and Turquoise Health have collaborated to provide accessible and affordable access to vital price transparency data. Ribbon Health’s API data platform collects data on every aspect of care, from quality to pricing, giving patients accurate information on their treatment costs.
To further boost the accuracy of its information, the company partnered with Turquoise Health’s pricing data from 4,500 hospitals. Nate Maslak, CEO and co-founder of Ribbon Health, stated that organizations must put the required patient-friendly pricing information, which could be easily understood without requiring specialized coding or technical expertise.
The machines’ raw data isn’t human-readable, and most website files are challenging to access and comprehend. A recent report shows that only 16% of 2,000 hospitals comply with CMS’ price transparency regulations. Ribbon Health’s unique approach involves sifting through data in raw format to reveal the practical nuts and bolts of real-time out-of-pocket pricing based on patients’ deductibles, contracted charges, and insurance plans, helping over half of Americans who say they are entirely lost about insurance plan costs.
Moreover, without in-depth information on providers, 20 million clinically inappropriate referrals occur each year in the U.S, according to the Ribbon Health website.
Ribbon Health collects data to power its directory, referral management, insurance enrollment, and care navigation. The platform determines the cost-effectiveness of care by comparing the quality of care with transparent prices. It also provides a wide array of information in various formats, ranging from an easy-to-read 10-point scale to itemized lists.
Hospitals that do not comply with CMS standards are fined between $300 and $10,000 per day, with fines capped at $5,500 per day. Ribbon Health provides an excellent opportunity for hospitals to access information that will motivate these care delivery organizations to ensure they share a patient-friendly and understandable machine-readable format of complex contracting data.