What The Price Transparency Rule Tells Us About Achieving EHR Interoperability

Thanks to the Cures Act and its associated information blocking rule, we can finally see the end of the road for info blocking practices. Now, how do we get a clearer view of what comes next?

One way to predict the future is by looking at similar rules changes. The Cures Act won’t be the first time in recent memory the federal government has given a wide-ranging data mandate to healthcare providers.

Case in point: the Hospital Price Transparency Rule, which took effect in January 2021. For the first time, hospitals have to publish a price list of “shoppable services” on their website. What’s more, the data has to be both

1. machine-readable and
2. consumer-friendly

if health systems want to stay in the good graces of the Department of Health and Human Services (HHS).

Notably, the rule also requires hospitals to show how different insurers pay different base rates for the same services. Multiple parties have filed suit, unsuccessfully, as this threatens to upset years of established negotiations - even though the previous arrangement wasn’t satisfactory as much as it was “how things have always been done”. 

So, after years of delays, hospitals are scrambling to make confidential data more accessible to third parties. Experts agree it’s time for this common sense change. The implications for consumers are enormous. But convincing a wide range of stakeholders is a huge challenge, and implementation is another. Sound familiar? 

You might have deja vu right now if you’ve ever worked towards health data interoperability. There’s a lot that the price transparency rule can teach us about upgrading health IT!

It’s More Than a Rule Change: It’s Figuring Out What Adoption Looks Like

When exactly does data become “consumer friendly”? Since some of the requirements are open to interpretation, hospitals have been sharing notes, FierceHealthcare reports. 

Successful organizations brought different departments together to agree on price list publication. Legal teams generally sought to release as little data as possible. Billing departments and medical staff wanted the rates to make sense. IT experts asked for an easy and sustainable process. Industry veterans have described months of work and well over $50,000 in costs per hospital to attempt initial compliance.

All in all, conversations around the price transparency rule aren’t much different than how various departments have their own priorities when safely importing and exporting PHI. 

Industry-wide understanding is growing as providers make their first attempts at price transparency together. It’s taking a sustained, shared effort to put this seemingly simple rule into practice.

Enforcement Is Serious Business

More than a few providers had trouble launching their price transparency initiative. 

A pair of studies conducted in early 2021 (in JAMA and the American Journal of Managed Care) showed that the vast majority of hospitals still hadn’t implemented the full HHS requirement. Although compliance rates are improving, researchers theorized that “the cost of disclosure of negotiated rates could be greater [for hospitals] than any fines.”

Nevertheless, regulators aren't accepting half-hearted attempts at this rule. In case financial penalties aren’t enough, they intend to get patients involved by prioritizing tip lines and releasing public lists of slacker hospitals. What’s more, CMS (the Centers for Medicaid and Medicare Services) has sent at least 256 warning letters to health systems of all sizes.

It took about six months after the rule took effect before those warning letters went out. In each letter, CMS demanded changes in 90 days, but gave providers one last chance before issuing any fines.

This is a rapid pace for the federal government. And they’re serious this time. No, really!

To show that CMS means business, they’ve increased the maximum price transparency penalty from $109,500 to $2,007,500 in 2022.

This 1,700% leap better aligns CMS with the $1,000,000 info blocking penalties from ONC (their HHS partner agency, and our chief info blocking enforcer).

A New Conversation: Research Is Driving Systemic Change

Despite compliance issues, price transparency is beginning to have its desired effect. A New York Times investigation last month revealed wild variations in price for the same procedures (to wit: one hospital billed different insurers $10 or $93 for the same pregnancy test). Data regulations are bringing the issues to light, as intended.

And that’s just the first wave of data-informed stories. Several years ago, Vox crowdsourced thousands of bills from its readers to form a rough understanding of this valuable data. Now, what would have been a multi-year investigation is a project that any researcher can take on.

Patient advocacy groups have taken note. Newly-indexed pricing data has even given individual patients a new avenue to advocate for themselves. As the implications of this broad rule take form, it heralds lower prices for consumers who make a bit of noise on their own behalf. Rest assured, if patients start discussing price disparities, then hospital board rooms will start talking about them too.

Plus, price transparency is informing other patient-centric rules. It’s already set the legal precedent for a similar insurance transparency rule targeted at health insurers, and it’s normalizing strong enforcement mechanisms for interoperability upgrades. 

Data Makes A Great Case for Transformative Apps

Now that data is not only legally accessible but machine-readable, health tech startups have found a way to enter the conversation.

Turquoise Health and Health Cost Labs, among others, have launched consumer-facing price comparison tools. Other hospitals are experimenting with their own homemade plugins. Engineering teams are leveraging their subject matter expertise to give context to fragmented data.

Still, the fact that patients need instruction on how to use this data remains an issue.

The price transparency rule, like health data portability, has broad support from the federal government. Similarly, it also came into being with the help of many friends in the healthcare space.

But changing the behavior of institutions and consumers remains to be seen. Stakeholders have an achievable goal, if they’re ready to push forward. ⚛️