March 18, 2019
Department of Health and Human Services
Office of the National Coordinator for Health Information Technology
21st Century Cures Act: Interoperability, Information Blocking,
and the ONC Health IT Certification Program Proposed Rule
Mary E. Switzer Building, Mail Stop:7033A
330 C Street SW
Washington, DC 20201
MMS Analytics, Inc. is pleased to submit a public comment in response to the Notice of Proposed Rulemaking to Improve the Interoperability of Health Information for a new rule to support seamless and secure access, exchange, and use of electronic health information (EHI) by the U.S. Department of Health and Human Services (HHS).
We applaud HHS and the Office of the National Coordinator for Health Information Technology (ONC) for their effort to improve the value of healthcare received by patients in the United States, and especially commend their recognition that “[i]ncreased consumer demand, aligned incentives, more accessible and digestible information, and the evolution of price transparency tools are critical components to moving to a health care system that pays for value.” We could not agree more.
MMS Analytics would like to take the opportunity to directly address some of the questions posed by the Office of the National Coordinator for Health Information Technology (ONC) in their document RIN 0955-AA01.
- “Should prices that are included in EHI reflect the amount to be charged to and paid for by the patient’s health plan (if the patient is insured) and the amount to be charged to and collected from the patient (as permitted by the provider’s agreement with the patient’s health plan), including for drugs or medical devices?”
Yes. It is important to note that charged amounts are of very limited value to patients—especially insured patients—because the charged amounts have very little impact on how much is actually paid for medical services. Therefore, it is absolutely critical that EHI-included prices reflect the amounts paid for by the patient’s health plan and collected from the patient for medical care.
- “Should prices that are included in EHI include various pricing information such as charge master price, negotiated prices, pricing based on CPT codes or DRGs, bundled prices, and price to payer?”
Prices included in EHI may include chargemaster rates for the sake of consumer perspective, but charged rates are not particularly useful for consumers. EHI-included prices need to include the insurance-negotiated discounted rates for medical tests and procedures based on CPT codes. These are the amounts that providers are actually paid by the health plan and/or patient. Where applicable, bundled prices should also be included (i.e. to identify the total costs associated with a multiple-component procedure such as a knee replacement surgery).
- “Should prices that are included in EHI be reasonably available in advance and at the point of sale?”
Patients need access to pricing information at the time that they are making the decision on whether or not to receive certain kinds of medical care, and where to receive their care. It is imperative that EHI-included pricing information be available to patients on demand, well in advance of receiving the care. The absolute latest that this information could be useful to a patient would be before the “point of sale,” which in the healthcare delivery model, occurs immediately before the test or procedure is performed on the patient. Of course, this so-called “point of sale” in healthcare may occur weeks or months before a receipt or invoice is generated by a provider—long before any patient might pay for the care. It is critical that any pricing information be made available to the patient before she or he makes the decision to receive the care in question in the first place.
- “Should prices that are included in EHI reflect all out-of-pocket costs such as deductibles, copayments, and coinsurance (for insured patients)?”
Yes, but HHS and ONC should be advised that these out-of-pocket costs do not tell the entire story. Copayments and coinsurance are often used as proxies for cost that insulate consumers from the total amounts actually paid to providers by the patients and their health plans. EHI-included prices should reflect out-of-pocket costs for the sake of clarity to the patients, but the total amount paid to the provider for rendering care must be included in the pricing for consumers.
- “Should prices that are included in EHI include a reference price as a comparison tool such as the Medicare rate and, if so, what is the most meaningful reference?”
It is important to provide patients with some context for procedure pricing so they can evaluate the value of the care in context. This is why it is important to make the pricing accessible in a way that can be easily compared across providers. Assigning a kind of reference price can be useful as well, although challenges present themselves in the form of varying costs by geographic region across the wide range of U.S. markets. MMS Analytics has developed a proprietary benchmark based on an adjusted median price that is granular enough to be applied across these varied markets.
- “To the extent that patients have a right to price information within a reasonable time in advance of care, how would such reasonableness be defined for:
- Scheduled care, including how far in advance should such pricing be available for patients still shopping for care, in addition to those who have already scheduled care?”
Pricing information should always be available to patients on demand. With current technology, patients should never need to wait to receive information about pricing. Whether a patient has already scheduled care, or is simply considering scheduling a given test or procedure, he or she should always have immediate access to accurate pricing information to inform their decision. Delays in accessing this information is not only inconvenient, or potentially financially costly, but these delays can also lead to avoidable medical complications.
- “How would price information vary based on the type of health insurance and/or payment structure being utilized, and what, if any, challenges would such variation create to identifying the price information that should be made available for access, exchange, or use?”
Negotiated rates for procedure pricing often varies based on a wide range of variables such as the health plan, the type of insurance product, whether or not the plan is self-funded or fully insured, etc. These nuances must be captured in any EHI-included prices, or patients may encounter rates that are not accurate or relevant with respect to their unique insurance plan or circumstances.
- “Should price information be made available on public web sites so that patients can shop for care without having to contact individual providers, and if so, who should be responsible for posting such information? Additionally, how would the public posting of pricing information through API technology help advance market competition and the ability of patients to shop for care?”
Yes. Price information must be made available on websites such that patients can comparison-shop for their medical care. If HHS were able to provide an API that served as a conduit to all of these procedure prices included in EHI, both public- and private-sector organizations could leverage that data to create websites, tools, and applications to benefit the consumer. One of the most difficult challenges that price transparency tools currently face is access to the pricing data. If HHS were to make this data available to the public, especially through a standardized API, it would unleash massive potential for building tools to empower consumers, help them control their healthcare costs, and drive down our per capita spending on medical care overall. In addition, this increased transparency would support the economic forces that would push providers to actually compete with each other based on price, and cause a secondary effect of many providers lowering their prices to gain higher patient volume, thus reducing overall costs even further. This effort could realistically save patients, their health plan sponsors, and the entire system hundreds of billions of dollars annually, and finally bend our nation’s healthcare cost curve downward after decades of relentless upward trends.
VP of Marketing
MMS Analytics, Inc. dba MyMedicalShopper