A major theme of the Trump Administration this year has been healthcare pricing, including surprise billing (here) and price transparency (for June 2019 executive order, here.) In late September, a number of stakeholder groups urged the Hill to move forward with surprise billing legislative, which had lost momentum.
For price transparency, the eagle has landed; on Friday, November 15, the Trump administration releases final and major price transparency regulations. HHS views price transparency as a matter it can address through de novo regulation, whereas most surprise billing issue fall outside of Medicare or Medicaid and would require legislation.
Somewhat confusingly, today's release has two different components, and one part is a second and "final" part to the annual OPPS final rule, most of which was released November 1 (here). In that rule, CMS merely stated concisely that "We intend to [issue] a forthcoming final rule." Here it is.
Then, there is also a separate PROPOSED rule, which has its own website and its own fact sheet.
Headline: The OPPS Final Rule "F2" governs hospital requirements for publishing price transparency. While I believe past state legislation has defined this as chargemasters, CMS defines this as per payor negotiated rates. All rates need to be available to a patient, but 300 key rates need to the public. Meanwhile, the PROPOSED rule is about insurers posting negotiated rates.
- For CMS/HHS press release, here.
- For CMS fact sheet on the rule (CMS-1717-F2), here.
- Those who want to read the 1717-F2 rule (in typescript form, 331pp), here.
- CMS webinar on the final rule here (Dec. 3).
- Now, there is also separate from that, a PROPOSED rule.
- For fact sheet on PROPOSED rule, (CMS-9915-P) here.
- Those who want to read the 9915-P rule (in typescript form, 219pp), here.
- Since 9915-P is a PROPOSED rule, it has a 60 day comment period (to mid January).
- For WSJ article, here.
- For a September background WSJ article, here. ("Push Sparks Furor")
- For a November 20 update, WSJ, hospitals vow to sue CMS, here.
- The Economist, Nov. 23 issue, Op Ed here. Deep dive article, same issue, here.
- Healthcare Dive here. Medcity News here. Pro's and Con's article at Vox, here.
- Health Affairs here.
- AHA and other hospital groups issued a joint statement that they disliked the rules here.
- Opponents gear up for the courtrom, here.
I haven't read these line by line. But for hospitals, CMS clearly asks them to post negotiated rates per payor, and CMS then asks them to post lowest and highest negotiated rate "anonymously." If I've listed ten payer rates by name from 1 to 10 for cost, then posting the lowest & highest rates anonymously seems impossible.
With all the fuss about transparency, all CMS prices have been posted online for a decade or two, physician offices, imaging, lab tests, hospital based surgery, inpatient, outpatient, drug prices, and so on. Nothing secret about all of that.
And with commercial insurers, while there has never been mandatory posting of contracted rates, either from the hospital side nor from the payer side, there's one thing hiding in plain site. These rates are sent out by the millions, tens of millions, hundreds of millions, into the public space via Explanations of Benefits. I know if my imaging center charged BCBS $1200, got paid $319, and my copay was $35. I know if my doctor charged BCBS $225 for an office visit, got paid $87, and my copay was $20. While these circulate by email, by postal mail, such agreements and rates circulate in society in hundreds of millions of documents. Easy to access? No. But different in a fundamental way from a true "secret."